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Yasin FA, Eldooma I. Diabetic Foot Care: Assessing the Knowledge and Practices of Diabetic Patients at Aldaraga Centre, Gezira State, Sudan, 2021. Diabetes Metab Syndr Obes 2024; 17:2495-2504. [PMID: 38910911 PMCID: PMC11193440 DOI: 10.2147/dmso.s453666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 06/14/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Improving diabetic patients' foot care behaviours is crucial in the incidence reduction of diabetic foot ulceration-associated complications. Objective This study assessed the knowledge and practice of diabetic patients towards diabetic foot care and their general understanding of diabetes causes, complications, and treatment. Methods A cross-sectional study was conducted at Aldaraga Clinic Centre, Sudan, with a sample size of 100 diabetic patients. A questionnaire and checklist were used to collect data for this study. The data was analyzed through SPSS Version 16 software. Results The majority of respondents were females (62%), above 40 years old (66%), married, with a low educational level, and moderate-income (76%). The study revealed that most respondents did not attend any educational program about diabetes, indicating poor or no knowledge about diabetes mellitus. However, respondents had good knowledge of most signs and symptoms of diabetes, with the highest percentage (88%) for extreme thirst. Concerning the knowledge of respondents about complications of diabetes, it was generally poor, except for retinal diseases (70%). Participants' knowledge of signs and symptoms of hypoglycemia was found to be poor at 25%. The study showed that most respondents did not know what diabetes gangrene is. Foot infections were the most dominant cause of hospitalization among diabetic patients, often leading to amputations. Conclusion Enhancing foot care behaviours in diabetic patients is crucial to reduce diabetic foot ulceration risks. Patient-friendly educational interventions and regular physician reinforcement are urgently needed, including awareness programs, specialized diabetes centres, and health education through mass media to improve foot care practices and prevent complications like amputations.
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Affiliation(s)
- Fakhreldin Ali Yasin
- Department of Family and Community Medicine, Faculty of Medicine University of Gezira, Wad-Medani, Sudan
| | - Ismaeil Eldooma
- Department of Planning, Research and Information, National Health Insurance Fund, Wad-Medani, Gezira State, Sudan
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Calcaterra V, Cena H, Pelizzo G, Porri D, Regalbuto C, Vinci F, Destro F, Vestri E, Verduci E, Bosetti A, Zuccotti G, Stanford FC. Bariatric Surgery in Adolescents: To Do or Not to Do? CHILDREN (BASEL, SWITZERLAND) 2021; 8:453. [PMID: 34072065 PMCID: PMC8204230 DOI: 10.3390/children8060453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 01/19/2023]
Abstract
Pediatric obesity is a multifaceted disease that can impact physical and mental health. It is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors. In most cases lifestyle and behavioral modification as well as medical treatment led to poor short-term weight reduction and long-term failure. Thus, bariatric surgery should be considered in adolescents with moderate to severe obesity who have previously participated in lifestyle interventions with unsuccessful outcomes. In particular, laparoscopic sleeve gastrectomy is considered the most commonly performed bariatric surgery worldwide. The procedure is safe and feasible. The efficacy of this weight loss surgical procedure has been demonstrated in pediatric age. Nevertheless, there are barriers at the patient, provider, and health system levels, to be removed. First and foremost, more efforts must be made to prevent decline in nutritional status that is frequent after bariatric surgery, and to avoid inadequate weight loss and weight regain, ensuring successful long-term treatment and allowing healthy growth. In this narrative review, we considered the rationale behind surgical treatment options, outcomes, and clinical indications in adolescents with severe obesity, focusing on LSG, nutritional management, and resolution of metabolic comorbidities.
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Affiliation(s)
- Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy;
- Pediatric Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (E.V.); (A.B.); (G.Z.)
| | - Hellas Cena
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, 27100 Pavia, Italy; (H.C.); (D.P.)
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (F.D.); (E.V.)
| | - Debora Porri
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, 27100 Pavia, Italy; (H.C.); (D.P.)
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Corrado Regalbuto
- Pediatric Unit, Fond. IRCCS Policlinico S. Matteo and University of Pavia, 27100 Pavia, Italy; (C.R.); (F.V.)
| | - Federica Vinci
- Pediatric Unit, Fond. IRCCS Policlinico S. Matteo and University of Pavia, 27100 Pavia, Italy; (C.R.); (F.V.)
| | - Francesca Destro
- Pediatric Surgery Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (F.D.); (E.V.)
| | - Elettra Vestri
- Pediatric Surgery Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (F.D.); (E.V.)
| | - Elvira Verduci
- Pediatric Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (E.V.); (A.B.); (G.Z.)
- Department of Health Sciences, University of Milan, 20146 Milan, Italy
| | - Alessandra Bosetti
- Pediatric Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (E.V.); (A.B.); (G.Z.)
| | - Gianvincenzo Zuccotti
- Pediatric Department, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (E.V.); (A.B.); (G.Z.)
- “L. Sacco” Department of Biomedical and Clinical Science, University of Milan, 20146 Milan, Italy
| | - Fatima Cody Stanford
- Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA;
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Bypassed and Preserved Stomach Resulted in Superior Glucose Control in Sprague-Dawley Rats with Streptozotocin-Induced Diabetes. Sci Rep 2019; 9:9981. [PMID: 31292518 PMCID: PMC6620334 DOI: 10.1038/s41598-019-46418-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 06/28/2019] [Indexed: 12/18/2022] Open
Abstract
Recent studies suggest the possibility of the stomach playing a role in diabetes remission after bariatric surgery. In this study, we investigated whether bypassing the stomach alleviates diabetes in diabetic rodent model. Eighteen moderately obese and diabetic Sprague-Dawley rats were randomly assigned to Esophagoduodenostomy with or without gastric preservation (EDG and EDNG/total gastrectomy, respectively), and SHAM groups. Bodyweight, food intake, fasting glucose level, oral glucose tolerance test result (OGTT), and hormone levels (insulin, glucagon-like peptide-1, ghrelin, gastrin and glucagon) were measured preoperative and postoperatively. Postoperatively, bodyweight and food intake did not differ significantly between the EDG and EDNG groups. Postoperative fasting blood glucose and OGTT results declined significantly in the EDG and EDNG group when compared with the respective preoperative levels. Postoperative glucose control improvements in EDNG group was significantly inferior when compared to EDG. Compared preoperatively, postoperative plasma ghrelin and gastrin levels declined significantly in EDNG group. Preoperative and postoperative plasma GLP-1 level did not differ significantly among all the groups. Postoperatively, EDG group had significantly higher insulin and lower glucagon levels when compared with SHAM. In conclusion, bypassing and preserving the stomach resulted in superior glucose control improvements than total gastrectomy.
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Nor Hanipah Z, Hsin MC, Liu CC, Huang CK. Laparoscopic loop duodenaljejunal bypass with sleeve gastrectomy in type 2 diabetic patients. Surg Obes Relat Dis 2019; 15:696-702. [PMID: 30935839 DOI: 10.1016/j.soard.2019.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/12/2019] [Accepted: 01/22/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Laparoscopic loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) is a new metabolic procedure. Our initial data on type 2 diabetes (T2D) remission after LDJB-SG were promising. OBJECTIVES The aim of this study was to look at our intermediate outcomes after LDJB-SG. SETTING An academic medical center. METHODS A prospective analysis of T2D patients who underwent LDJB-SG between October 2011 and October 2014 was performed. Data collected included baseline demographic, body mass index, fasting blood glucose, glycosylated hemoglobin, C-peptide, resolution of co-morbidities, and postoperative complications. RESULTS A total of 163 patients with minimum of follow-up >1 year were enrolled in this study (57 men and 106 women). The mean age and body mass index were 47.7 (±10.7) years and a 30.2 (±5.1) kg/m2, respectively. There were 119 patients on oral hypoglycemic agents only, 29 patients were on oral hypoglycemic agents and insulin, 3 patients were on insulin only, and the other 12 patients were not on diabetic medication. Mean operation time and length of hospital stay were 144.7 (± 45.1) minutes and 2.4 (± 1.0) days, respectively. Seven patients (3.6%) needed reoperation due to bleeding (n = 1), anastomotic leak (n = 2), sleeve strictures (n = 2), and incisional hernia (n = 2). At 2 years of follow-up, there were 56 patients. None of the patients were on insulin and only 20% of patients were on oral hypoglycemic agents. Mean body mass index significantly dropped to 22.9 (±5.6) kg/m2 at 2 years. The mean preoperative fasting blood glucose, glycosylated hemoglobin, and C-peptide levels were 174.7 mg/dL (± 61.0), 8.8% (±1.8), and 2.6 (±1.7) ng/mL, respectively. The mean fasting blood glucose, glycosylated hemoglobin, and C-peptide at 2 years were 112.5 (±60.7) mg/dL, 6.4% (±2.0), and 1.5 (±0.6) ng/mL, respectively. No patient needed revisional surgery because of dumping syndrome, marginal ulcer, or gastroesophageal reflux disease at the last follow up period. CONCLUSION At 2 years, LDJB-SG is a relatively safe and effective metabolic surgery with significant weight loss and resolution of co-morbidities.
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Affiliation(s)
- Zubaidah Nor Hanipah
- Body Science & Metabolic Disorders International (BMI) Medical Center, China Medical University Hospital, Taichung City, Taiwan (ROC); Department of General Surgery, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
| | - Ming-Che Hsin
- Body Science & Metabolic Disorders International (BMI) Medical Center, China Medical University Hospital, Taichung City, Taiwan (ROC)
| | - Chia-Chia Liu
- Body Science & Metabolic Disorders International (BMI) Medical Center, China Medical University Hospital, Taichung City, Taiwan (ROC)
| | - Chih-Kun Huang
- Body Science & Metabolic Disorders International (BMI) Medical Center, China Medical University Hospital, Taichung City, Taiwan (ROC).
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Liang Y, Wang Y, Qiao Z, Cao T, Feng Y, Zhang L, Zhang P. Duodenal-Jejunal Bypass Surgery Reverses Diabetic Phenotype and Reduces Obesity in db/db Mice. Curr Chem Genom Transl Med 2017; 11:41-49. [PMID: 29238655 PMCID: PMC5712635 DOI: 10.2174/2213988501711010041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 09/08/2017] [Accepted: 10/18/2017] [Indexed: 11/22/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM), a complex metabolic disorder typically accompanying weight gain, is associated with progressive β-cell failure and insulin resistance. Bariatric surgery ameliorates glucose tolerance and provides a near-perfect treatment. Duodenal-jejunal bypass (DJB) is an experimental procedure and has been studied in several rat models, but its influence in db/db mice, a transgenic model of T2DM, remains unclear. To investigate the effectiveness of DJB in db/db mice, we performed the surgery and evaluated metabolism improvement. Results showed that mice in DJB group weighed remarkably less than sham group two weeks after surgery. Compared to the preoperative level, postoperative fasting blood glucose (FBG) was dramatically reduced. Statistical analysis revealed that changes in body weight and FBG were significantly correlated. Besides, DJB surgery altered plasma insulin level with approximate 40% reduction. Thus, for the first time we proved that DJB can achieve rapid therapeutic effect in transgenic db/db mice with severe T2DM as well as obesity. In addition, decreased insulin level reflected better insulin sensitivity induced by DJB. In conclusion, our study demonstrates that DJB surgery may be a potentially effective way to treat obesity-associated T2DM.
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Affiliation(s)
- Yongjun Liang
- Center for Medical Research and Innovation, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, , P.R. China
| | - Yueqian Wang
- Center for Medical Research and Innovation, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, , P.R. China
| | - Zhengdong Qiao
- Center for Medical Research and Innovation, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, , P.R. China
| | - Ting Cao
- Center for Medical Research and Innovation, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, , P.R. China
| | - Ying Feng
- Laboratory of Molecular Neuropharmacology, School of Pharmacy, East China University of Science and Technology, 130 Meilong Road, , P.R. China
| | - Lin Zhang
- Laboratory of Molecular Neuropharmacology, School of Pharmacy, East China University of Science and Technology, 130 Meilong Road, , P.R. China
| | - Peng Zhang
- Center for Medical Research and Innovation, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, , P.R. China
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Kim DJ, Paik KY, Kim MK, Kim E, Kim W. Three-year result of efficacy for type 2 diabetes mellitus control between laparoscopic duodenojejunal bypass compared with laparoscopic Roux-en-Y gastric bypass. Ann Surg Treat Res 2017; 93:260-265. [PMID: 29184879 PMCID: PMC5694717 DOI: 10.4174/astr.2017.93.5.260] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/12/2017] [Accepted: 04/21/2017] [Indexed: 12/15/2022] Open
Abstract
Purpose The mechanism by which bariatric surgery facilitates diabetic control is still unknown. Duodenojejunal bypass supports the foregut theory; however, its efficacy when used alone is not yet established. Methods During the period from January 2008 to December 2009, patients who underwent laparoscopic duodenojejunal bypass (LDJB) or laparoscopic Roux-en-Y gastric bypass (LRYGB) for type 2 diabetes mellitus (T2DM) with or without morbid obesity were included. Patients who had a follow-up for less than 3 years were excluded. Patient baseline characteristics, change of body weight, body mass index (BMI), glycosylated hemoglobin (HbA1c), and diabetic treatments were analyzed. Results In total, 8 LDJB and 20 LRYGB patients were analyzed. The LDJB group had more number of male patients than the LRYGB group (LDJB 75% vs. LRYGB 30%, P = 0.030). Baseline BMI in the LRYGB group was higher than in the LDJB group (LDJB 27.0 ± 2.5 vs. LRYGB 32.6 ± 3.4, P < 0.001). Age, DM duration, baseline HbA1c, and C-peptide levels were similar. Longer operation time was needed to perform LDJB (LDJB 367.5 ± 120.2 vs. LRYGB 232.9 ± 41.1, P < 0.001), but no differences were observed in the hospital stay and complication rate between the 2 groups. At the third year of follow-up, the T2DM remission rate was observed in 40% of patients in the LRYGB group and 12.5% of patients in the LDJB group. Conclusion LDJB is not an effective method for controlling T2DM compared with LRYGB. Foregut theory may not be the main mechanism of diabetic control during bariatric surgery.
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Affiliation(s)
- Dong Jin Kim
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang Yeol Paik
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mee Kyoung Kim
- Department of Endocrinology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eungkook Kim
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wook Kim
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Fenger M, Hansen DL, Worm D, Hvolris L, Kristiansen VB, Carlsson ER, Madsbad S. Gastric bypass surgery reveals independency of obesity and diabetes melitus type 2. BMC Endocr Disord 2016; 16:59. [PMID: 27829412 PMCID: PMC5103622 DOI: 10.1186/s12902-016-0140-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 10/21/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Roux-en-Y gastric bypass surgery is widely applied to ameliorate morbid obesity, including diabetes in people with type 2 diabetes. The latter vanish a few days after surgery for many, but not in all patients before any weight reduction has occurred. The explanation for this change in metabolic status is poorly understood, but the observation may suggest that the fate obesity and diabetes is only partly linked after surgery. METHODS The trajectories of weight reduction measured as reduced body mass index (BMI) in 741obese subjects with and without diabetes were evaluated. Evaluation was performed on three groups: 1) subjects that were non-diabetic before and after surgery; 2) subjects that were diabetics before surgery but non-diabetics after surgery; and 3) subjects that were diabetics before surgery and remained diabetics after surgery. The diabetic state was established at HbA1c above 48 mmol/mol. RESULTS The trajectories differ significantly between groups and any sub-populations of groups, the latter identified by the distance between individual trajectories using a k-means procedure. The results suggest that different domains in the enormous genetic network governing basic metabolism are perturbed in obesity and diabetes, and in fact some of the patients are affected by two distinct diseases: obesity and diabetes mellitus type 2. CONCLUSION Although RYGB "normalized" many glycaemic parameters in some of the diabetic subjects apparently converting to a non-diabetics state, other diabetic subjects stay diabetic in the context of the new gut anatomy after surgery. Thus, the obesity part of the glycaemic derangement may have been ameliorated, but some defects of the diabetic state had not.
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Affiliation(s)
- Mogens Fenger
- Department of Clinical Biochemistry, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
| | | | - Dorte Worm
- Department of Clinical Medicine, University Hospital of Zeeland, Køge, Denmark
| | - Lisbeth Hvolris
- Department of Surgical Gastroenterology, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
| | - Viggo B. Kristiansen
- Department of Surgical Gastroenterology, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
| | - Elin Rebecka Carlsson
- Department of Clinical Biochemistry, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
| | - Sten Madsbad
- Department of Endocrinology, University Hospital of Copenhagen, Kettegaards Alle 30, 2650 Hvidovre, Denmark
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Surgical cure for type 2 diabetes by foregut or hindgut operations: a myth or reality? A systematic review. Surg Endosc 2016; 31:25-37. [PMID: 27194257 DOI: 10.1007/s00464-016-4952-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/18/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bariatric surgery results in remission of type 2 diabetes mellitus in a significant proportion of patients. Animal research has proposed the foregut and hindgut hypotheses as possible mechanisms of remission of T2DM independent of weight loss. These hypotheses have formed the basis of investigational procedures designed to treat T2DM in non-obese (in addition to obese) patients. The aim of this study was to review the procedures that utilise the foregut and hindgut hypotheses to treat T2DM in humans. METHODS A systematic review was conducted to identify the investigational procedures performed in humans that are based on the foregut and hindgut hypotheses and then to assess their outcomes. RESULTS Twenty-four studies reported novel procedures to treat T2DM in humans; only ten utilised glycated haemoglobin A1c (HbA1c) in their definition of remission. Reported remission rates were 20-40 % for duodenal-jejunal bypass (DJB), 73-93 % for duodenal-jejunal bypass with sleeve gastrectomy (DJB-SG), 62.5-100 % for duodenal-jejunal bypass sleeve (DJBS) and 47-95.7 % for ileal interposition with sleeve gastrectomy (II-SG). When using a predetermined level of HbA1c to define remission, the remission rates were lower (27, 63, 0 and 65 %) for DJB, DJB-SG, DJBS and II-SG. CONCLUSIONS The outcomes of the foregut- and hindgut-based procedures are not better than the outcomes of just one of their components, namely sleeve gastrectomy. The complexity of these procedures in addition to their comparable outcomes to a simpler operation questions their utility.
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Lee SK, Kwon OJ, Jeon HM, Kim SJ. Long-term effects of duodenojejunal bypass on diabetes in Otsuka Long-Evans Tokushima Fatty rats. Asian J Surg 2016; 40:262-269. [PMID: 26787497 DOI: 10.1016/j.asjsur.2015.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 10/20/2015] [Accepted: 11/16/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Previous studies have shown that duodenojejunal bypass (DJB) resolves type 2 diabetes. However, this finding has been contradicted by several experimental and human trials and therefore needs to be clarified. METHODS Otsuka Long-Evans Tokushima Fatty (OLETF) rats randomly underwent a sham operation or DJB. Thereafter, we measured daily body weight, serum levels of glucose and gut hormones such as glucagon-like peptide-1, insulin, and leptin. RESULTS There was no significant difference in weight loss between rats in the DJB and sham-operated groups. There were also no differences in the area under the curve of glucose tolerance between the DJB and sham-operated groups (32466 ± 2261 mg/dL·min vs. 26319 ± 427 mg/dL·min; p = 0.35). Duodenojejunal bypass did not affect plasma concentrations of various gut hormones such as glucagon-like peptide-1, insulin, and leptin. CONCLUSIONS We have shown that DJB alone does not improve glucose tolerance in obese, diabetic OLETF rats. Therefore, it may be that DJB alone is insufficient for diabetic control in obese diabetic rats. The addition of a restrictive component such as sleeve gastrectomy, or a new drug may be necessary for achieving diabetes reversal.
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Affiliation(s)
- Sang Kuon Lee
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, Catholic University of Korea, Daejeon, Republic of Korea
| | - Oh-Joo Kwon
- Department of Biochemistry, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Hae Myung Jeon
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Say-June Kim
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, Catholic University of Korea, Daejeon, Republic of Korea.
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Duodenojejunal Bypass Leads to Altered Gut Microbiota and Strengthened Epithelial Barriers in Rats. Obes Surg 2015; 26:1576-83. [DOI: 10.1007/s11695-015-1968-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Roux-en Y gastric bypass is superior to duodeno-jejunal bypass in improving glycaemic control in Zucker diabetic fatty rats. Obes Surg 2015; 24:1888-95. [PMID: 24927690 DOI: 10.1007/s11695-014-1301-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Whilst weight loss results in many beneficial metabolic consequences, the immediate improvement in glycaemia after Roux-en-Y Gastric bypass (RYGB) remains intriguing. Duodenal jejunal bypass (DJB) induces similar glycaemic effects, while not affecting calorie intake or weight loss. We studied diabetic ZDF(fa/fa) rats to compare the effects of DJB and RYGB operations on glycaemia. METHODS Male ZDF(fa/fa) rats, aged 12 weeks underwent RYGB, DJB or sham operations. Unoperated ZDF(fa/fa) and ZDF(fa/+w)ere used as controls. Body weight, food intake, fasting glucose, insulin and gut hormones were measured at baseline and on postoperative days 2, 10 and 35. An oral glucose tolerance test (OGTT) was performed on days 12 and 26. RESULTS DJB had similar food intake and body weight to sham-operated and unoperated control ZDF(fa/fa) rats (p = NS), but had lower fasting glucose (p < 0.05). RYGB had lower food intake, body weight and fasting glucose compared to all groups (p < 0.001). DJB prevented the progressive decline in fasting insulin observed in the sham-operated or unoperated ZDF(fa/fa) rats, while RYGB with normalized glycaemia reduced the physiological requirement for raised fasting insulin. CONCLUSIONS Bypassing the proximal small bowel with the DJB has mild to moderate body weight independent effects on glucose homeostasis and preservation of fasting insulin levels in the medium term. These effects might be further amplified by the additional anatomical and physiological changes after RYGB.
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Busetto L, Dixon J, De Luca M, Shikora S, Pories W, Angrisani L. Bariatric surgery in class I obesity : a Position Statement from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). Obes Surg 2015; 24:487-519. [PMID: 24638958 DOI: 10.1007/s11695-014-1214-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Class I obesity conveys an increased risk of comorbidities, impairs physical and mental health-related quality of life, and it is associated to an increased psychosocial burden, particularly in women. The need for effective and safe therapies for class I obesity is great and not yet met by nonsurgical approaches. Eligibility to bariatric surgery has been largely based on body mass index (BMI) cut points and limited to patients with more severe obesity levels. However, obese patients belonging to the same BMI class may have very different levels of health, risk, and impact of obesity on quality of life. Individual patients in class I obesity may have a comorbidity burden similar to, or greater than, patients with more severe obesity. Therefore, the denial of bariatric surgery to a patient with class I obesity suffering from a significant obesity-related health burden and not achieving weight control with nonsurgical therapy simply on the basis of the BMI level does not appear to be clinically justified. A clinical decision should be based on a more comprehensive evaluation of the patient's current global health and on a more reliable prediction of future morbidity and mortality. After a careful review of available data about safety and efficacy of bariatric surgery in patients with class I obesity, this panel reached a consensus on ten clinical recommendations.
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Affiliation(s)
- Luca Busetto
- Department of Medicine, University of Padua, Padua, Italy,
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Rao WS, Shan CX, Zhang W, Jiang DZ, Qiu M. A meta-analysis of short-term outcomes of patients with type 2 diabetes mellitus and BMI ≤ 35 kg/m2 undergoing Roux-en-Y gastric bypass. World J Surg 2015; 39:223-30. [PMID: 25159119 DOI: 10.1007/s00268-014-2751-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is effective for type 2 diabetes mellitus (T2DM) patients with a body mass index (BMI) >35 kg/m(2). It is unknown whether it benefits those with a BMI ≤ 35 kg/m(2). In the last decade, the effect of bariatric procedures on metabolic outcomes in individuals who underwent surgery outside National Institutes of Health (NIH) guidelines (BMI ≤ 35 kg/m(2)) was both interesting and controversial. OBJECTIVE We performed a systematic analysis evaluating the effect of RYGB for T2DM patients with a BMI ≤ 35 kg/m(2). METHODS We searched databases (Embase, Ovid, PubMed, China National Knowledge Infrastructure [CNKI], and Cochrane Library) and relevant journals between January 1980 and October 2013. Keywords used in electronic searching included 'diabetes', 'gastric bypass', 'BMI', and 'body mass index'. Inclusion criteria were as follows: (1) patients who underwent RYGB; (2) sample size ≥ 15; (3) patients with a BMI ≤ 35 kg/m(2); and (4) follow-up ≥ 12 months. Exclusion criteria were as follows: (1) data extracted from a database; (2) trials for sleeve gastrectomy; (3) trials for laparoscopic banding; (4) trials for bilio-pancreatic diversion; and (5) trials for duodenojejunal bypass. Participants and intervention type 2 diabetes patients with BMI ≤ 35 kg/m(2) who underwent RYGB. Two investigators reviewed all reported studies independently. Data were extracted according to previously defined endpoints. A meta-analysis was performed for these parameters, with homogeneity among different trials. RESULTS Nine articles fulfilled inclusion criteria. After 12 months, patients with T2DM had a significant decrease in their BMI postoperatively (p < 0.00001, weighted mean difference [WMD] -7.42, 95 % confidence interval [CI] -8.87 to -5.97), and remission of diabetes (glucose: p < 0.00001, WMD -59.87, 95 % CI -67.74 to -52.01; hemoglobin A1c p < 0.00001, WMD -2.76, 95 % CI -3.41 to -2.11). There were no deaths in all trials, and the complication rate was between 6.7 and 25.9 %. Mean length of hospital stay was 2.00 to 3.20 days, and mean operative time was from 72.8 to 112.0 min. In terms of study limitations, publication and selection bias were unavoidable. Trials with small sample sizes were excluded, which may lead to a selection bias. CONCLUSION RYGB was effective for T2DM patients with BMI ≤ 35 kg/m(2). Further clinical studies with long-term follow-up data are necessary to clarify this issue.
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Affiliation(s)
- Wen-Sheng Rao
- Department of General Surgery, Shanghai Changzheng Hospital, Affiliated to the Second Military Medical University, 415 FengYang Road, Huangpu District, Shanghai, 200003, China
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Kim JW, Kim KY, Lee SC, Yang DH, Kim BC. The effect of long Roux-en-Y gastrojejunostomy in gastric cancer patients with type 2 diabetes and body mass index < 35 kg/m(2): preliminary results. Ann Surg Treat Res 2015; 88:215-21. [PMID: 25844356 PMCID: PMC4384281 DOI: 10.4174/astr.2015.88.4.215] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/06/2014] [Accepted: 10/13/2014] [Indexed: 01/19/2023] Open
Abstract
Purpose We applied a long Roux-en-Y (RY) gastrojejunostomy (bypassed jejunum over 100 cm) as a reconstruction method for diabetes control to gastric cancer patients with type 2 diabetes and body mass index (BMI) < 35 kg/m2. The effect of this procedure on diabetes control was assessed. Methods We prospectively performed modified RY gastrojejunostmy after curative radical distal gastrectomy. Thirty patients had completed a 1-year follow-up. Patients were followed concerning their diabetic status. The factors included in the investigation were length of bypassed jejunum, BMI and its reduction ratio, glycated hemoglobin (HbA1c), fasting blood glucose, and duration of diabetes. Diabetic status after surgery was assessed in three categories: remission, improvement, and stationary. In evaluation of surgical effects on diabetes control, remission and improvement groups were regarded as effective groups, while stationary was regarded as an ineffective group. Results At postoperative one year, statistical significance was observed in the mean BMI and HbA1c. Diabetes control was achieved in 50% of the patients (remission, 30%; improvement, 20%). BMI reduction ratio, preoperative HbA1c, and duration of diabetes were correlated to the status of type 2 diabetes mellitus. The preoperative HbA1c was the most influential predictor in diabetic control. Conclusion The effect of long RY gastrojejunostomy after gastrectomy for diabetes control could be contentious but an applicable reconstruction method for diabetes control in gastric cancer patients with type 2 diabetes and BMI < 35 kg/m2. Diabetes remission is expected to be higher in patients with greater BMI reduction, short duration of diabetes, and lower preoperative HbA1c.
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Affiliation(s)
- Ji Won Kim
- Department of Surgery, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Kwang Yong Kim
- Department of Surgery, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Seung Chul Lee
- Department of Surgery, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Dae Hyun Yang
- Department of Surgery, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Byung Chun Kim
- Department of Surgery, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Lee WJ, Almulaifi AM, Tsou JJ, Ser KH, Lee YC, Chen SC. Duodenal-jejunal bypass with sleeve gastrectomy versus the sleeve gastrectomy procedure alone: the role of duodenal exclusion. Surg Obes Relat Dis 2014; 11:765-70. [PMID: 25813754 DOI: 10.1016/j.soard.2014.12.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 12/06/2014] [Accepted: 12/15/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypass with sleeve gastrectomy (DJB-SG). OBJECTIVES The aim of this study was to compare one-year results between DJB-SG and SG. SETTING University hospital. METHODS A total of 89 patients who received a DJB-SG surgery were matched with a group of SG that were equal in age, sex, and body mass index (BMI). Complication rates, weight loss, and remission of co-morbidities were evaluated after 12 months. RESULTS The mean preoperative patient BMI in the DJB-SG and SG groups was similar. There were more patients with type 2 diabetes mellitus (T2DM) in the DJB-SG group than in the SG group. The mean operative time and length of hospital stay (LOS) were significantly longer in the DJB-SG group than in the SG group. At 12 months after surgery, the BMI was lower and excess weight loss higher in DJB-SG than SG. Remission of T2DM was greater in the DJB-SG group. Low-density lipoprotein, total cholesterol, and metabolic syndrome (MS) improved after operation in both groups. CONCLUSIONS In this study DJB-SG was superior to SG in T2DM remission, triglyceride improvement, excess weight loss, and lower BMI at 1 year after surgery. Adding duodenal switch to sleeve gastrectomy increases the effect of diabetic control and MS resolution.
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Affiliation(s)
- Wei-Jei Lee
- Department of Surgery, Min-Sheng General Hospital, Taiwan.
| | | | - Jun-Juin Tsou
- Department of Surgery, Min-Sheng General Hospital, Taiwan
| | - Kong-Han Ser
- Department of Surgery, Min-Sheng General Hospital, Taiwan
| | - Yi-Chih Lee
- Department of International Business, Chien Hsin University of Science and Technology, Taiwan
| | - Shu-Chun Chen
- Department of Surgery, Min-Sheng General Hospital, Taiwan
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Abstract
BACKGROUND Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009. OBJECTIVES To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities. SEARCH METHODS Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures. DATA COLLECTION AND ANALYSIS Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument. MAIN RESULTS Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB. No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence). QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation. AUTHORS' CONCLUSIONS Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only. Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.
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Affiliation(s)
- Jill L Colquitt
- University of SouthamptonSouthampton Health Technology Assessments CentreFirst Floor, Epsilon House, Enterprise Road, Southampton Science Park, ChilworthSouthamptonHampshireUKSO16 7NS
| | - Karen Pickett
- University of SouthamptonSouthampton Health Technology Assessments CentreFirst Floor, Epsilon House, Enterprise Road, Southampton Science Park, ChilworthSouthamptonHampshireUKSO16 7NS
| | - Emma Loveman
- University of SouthamptonSouthampton Health Technology Assessments CentreFirst Floor, Epsilon House, Enterprise Road, Southampton Science Park, ChilworthSouthamptonHampshireUKSO16 7NS
| | - Geoff K Frampton
- University of SouthamptonSouthampton Health Technology Assessments CentreFirst Floor, Epsilon House, Enterprise Road, Southampton Science Park, ChilworthSouthamptonHampshireUKSO16 7NS
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Ngiam KY, Lee WJ, Lee YC, Cheng A. Efficacy of metabolic surgery on HbA1c decrease in type 2 diabetes mellitus patients with BMI <35 kg/m2--a review. Obes Surg 2014; 24:148-58. [PMID: 24242843 DOI: 10.1007/s11695-013-1112-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
High glycated hemoglobin A1c (HbA1c) is strongly correlated with developing type 2 diabetes mellitus (T2DM) complications; this study reviews the efficacy of various types of metabolic surgeries in reducing HbA1c levels in type 2 diabetics with BMI <35 kg/m(2). An electronic search of MEDLINE databases using terms 'metabolic surgery', type 2 diabetes mellitus, BMI <35 kg/m(2), and related keywords for studies published between 1987 and 2013. Data from 53 articles with 2,258 patients were selected for this review. The weighted mean change in HbA1c was -2.8 % (95 % CI -2.8 to -2.7, p < 0.01) and weighted mean BMI change was -5.5 kg/m(2) (95 % CI -5.6 to -5.4, p < 0.01). There was a strong correlation between weighted percentage mean change in HbA1c and BMI. Adjustable gastric banding and duodenal jejunal bypass were inferior to other surgeries in reducing BMI and HbA1c in BMI <35 kg/m(2). Metabolic surgery significantly decreases HbA1c in T2DM patients with BMI <35 kg/m(2) and that the magnitude of HbA1c change may be a useful surrogate of DM control.
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Affiliation(s)
- Kee Yuan Ngiam
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828
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18
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Wentworth JM, Playfair J, Laurie C, Ritchie ME, Brown WA, Burton P, Shaw JE, O'Brien PE. Multidisciplinary diabetes care with and without bariatric surgery in overweight people: a randomised controlled trial. Lancet Diabetes Endocrinol 2014; 2:545-52. [PMID: 24731535 DOI: 10.1016/s2213-8587(14)70066-x] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Bariatric surgery improves glycaemia in obese people with type 2 diabetes, but its effects are uncertain in overweight people with this disease. We aimed to identify whether laparoscopic adjustable gastric band surgery can improve glucose control in people with type 2 diabetes who were overweight but not obese. METHODS We did an open-label, parallel-group, randomised controlled trial between Nov 1, 2009, and June 30, 2013, at one centre in Melbourne, Australia. Patients aged 18-65 years with type 2 diabetes and a BMI between 25 and 30 kg/m2 were randomly assigned (1:1), by computer-generated random sequence, to receive either multidisciplinary diabetes care plus laparoscopic adjustable gastric band surgery or multidisciplinary diabetes care alone. The primary outcome was diabetes remission 2 years after randomisation, defined as glucose concentrations of less than 7.0 mmol/L when fasting and less than 11.1 mmol/L 2 h after 75 g oral glucose, at least two days after stopping glucose-lowering drugs. Analysis was by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000286246. FINDINGS 51 patients were randomised to the multidisciplinary care plus gastric band group (n=25) or the multidisciplinary care only group (n=26), of whom 23 participants and 25 participants, respectively, completed follow-up to 2 years. 12 (52%) participants in the multidisciplinary care plus gastric band group and two (8%) participants in the multidisciplinary care only group achieved diabetes remission (difference in proportions 0.44, 95% CI 0.17-0.71; p=0.0012). One (4%) participant in the gastric band group needed revisional surgery and four others (17%) had a total of five episodes of food intolerance due to excessive adjustment of the band. INTERPRETATION When added to multidisciplinary care, laparoscopic adjustable gastric band surgery for overweight people with type 2 diabetes improves glycaemic control with an acceptable adverse event profile. Laparoscopic adjustable gastric band surgery is a reasonable treatment option for this population. FUNDING Monash University Centre for Obesity Research and Education and Allergan.
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Affiliation(s)
- John M Wentworth
- Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia; Molecular Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, Australia
| | - Julie Playfair
- Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia
| | - Cheryl Laurie
- Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia
| | - Matthew E Ritchie
- Molecular Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, Australia
| | - Wendy A Brown
- Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia
| | - Paul Burton
- Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia
| | - Jonathan E Shaw
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Paul E O'Brien
- Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia.
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Jiang F, Zhu H, Zheng X, Tu J, Zhang W, Xie X. Duodenal-jejunal bypass for the treatment of type 2 diabetes in Chinese patients with an average body mass index<24 kg/m2. Surg Obes Relat Dis 2014; 10:641-6. [DOI: 10.1016/j.soard.2013.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 09/02/2013] [Accepted: 09/05/2013] [Indexed: 10/26/2022]
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20
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Muñoz R, Escalona A. Duodenal-Jejunal Bypass Liner to Treat Type 2 Diabetes Mellitus in Morbidly Obese Patients. Curr Cardiol Rep 2014; 16:454. [DOI: 10.1007/s11886-013-0454-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Quercia I, Dutia R, Kotler DP, Belsley S, Laferrère B. Gastrointestinal changes after bariatric surgery. DIABETES & METABOLISM 2013; 40:87-94. [PMID: 24359701 DOI: 10.1016/j.diabet.2013.11.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 11/21/2013] [Accepted: 11/22/2013] [Indexed: 12/23/2022]
Abstract
Severe obesity is a preeminent health care problem that impacts overall health and survival. The most effective treatment for severe obesity is bariatric surgery, an intervention that not only maintains long-term weight loss but also is associated with improvement or remission of several comorbidies including type 2 diabetes mellitus. Some weight loss surgeries modify the gastrointestinal anatomy and physiology, including the secretions and actions of gut peptides. This review describes how bariatric surgery alters the patterns of gastrointestinal motility, nutrient digestion and absorption, gut peptide release, bile acids and the gut microflora, and how these changes alter energy homeostasis and glucose metabolism.
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Affiliation(s)
- I Quercia
- New York Obesity Nutrition Research Center, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1111, Amsterdam Avenue, 1034 New York, NY 10025, USA; Department of Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA
| | - R Dutia
- New York Obesity Nutrition Research Center, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1111, Amsterdam Avenue, 1034 New York, NY 10025, USA; Department of Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA
| | - D P Kotler
- Division of Gastroenterology and Liver Disease, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Department of Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Columbia University College of Physicians and Surgeons, New York, NY 10025, USA
| | - S Belsley
- Department of Surgery, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Columbia University College of Physicians and Surgeons, New York, NY 10025, USA
| | - B Laferrère
- New York Obesity Nutrition Research Center, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1111, Amsterdam Avenue, 1034 New York, NY 10025, USA; Division of Endocrinology, Diabetes and Nutrition, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Department of Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Columbia University College of Physicians and Surgeons, New York, NY 10025, USA.
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Allen RE, Hughes TD, Ng JL, Ortiz RD, Ghantous MA, Bouhali O, Froguel P, Arredouani A. Mechanisms behind the immediate effects of Roux-en-Y gastric bypass surgery on type 2 diabetes. Theor Biol Med Model 2013; 10:45. [PMID: 23849268 PMCID: PMC3726422 DOI: 10.1186/1742-4682-10-45] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 07/10/2013] [Indexed: 02/08/2023] Open
Abstract
Background The most common bariatric surgery, Roux-en-Y gastric bypass, leads to glycemia normalization in most patients long before there is any appreciable weight loss. This effect is too large to be attributed purely to caloric restriction, so a number of other mechanisms have been proposed. The most popular hypothesis is enhanced production of an incretin, active glucagon-like peptide-1 (GLP-1), in the lower intestine. We therefore set out to test this hypothesis with a model which is simple enough to be robust and credible. Method Our method involves (1) setting up a set of time-dependent equations for the concentrations of the most relevant species, (2) considering an “adiabatic” (or quasi-equilibrium) state in which the concentrations are slowly varying compared to reaction rates (and which in the present case is a postprandial state), and (3) solving for the dependent concentrations (of e.g. insulin and glucose) as an independent concentration (of e.g. GLP-1) is varied. Results Even in the most favorable scenario, with maximal values for (i) the increase in active GLP-1 concentration and (ii) the effect of GLP-1 on insulin production, enhancement of GLP-1 alone cannot account for the observations. I.e., the largest possible decrease in glucose predicted by the model is smaller than reported decreases, and the model predicts no decrease whatsoever in glucose ×insulin, in contrast to large observed decreases in homeostatic model assessment insulin resistance (HOMA-IR). On the other hand, both effects can be accounted for if the surgery leads to a substantial increase in some substance that opens an alternative insulin-independent pathway for glucose transport into muscle cells, which perhaps uses the same intracellular pool of GLUT-4 that is employed in an established insulin-independent pathway stimulated by muscle contraction during exercise. Conclusions Glycemia normalization following Roux-en-Y gastric bypass is undoubtedly caused by a variety of mechanisms, which may include caloric restriction, enhanced GLP-1, and perhaps others proposed in earlier papers on this subject. However, the present results suggest that another possible mechanism should be added to the list of candidates: enhanced production in the lower intestine of a substance which opens an alternative insulin-independent pathway for glucose transport.
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Affiliation(s)
- Roland E Allen
- Department of Physics and Astronomy, Texas A&M University, College Station, TX 77843, USA.
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Zhu L, Mo Z, Yang X, Liu S, Wang G, Li P, Tan J, Ye F, Strain J, Im I, Zhu S. Effect of laparoscopic Roux-en-Y gastroenterostomy with BMI<35 kg/m(2) in type 2 diabetes mellitus. Obes Surg 2013; 22:1562-7. [PMID: 22692669 DOI: 10.1007/s11695-012-0694-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RGB) has been endorsed by the "First World Congress on International Therapies for Type 2 diabetes" as a possible therapeutic option in patients with type 2 diabetes with a body mass index (BMI) of less than 35 kg/m(2). In the present study, we assessed the improvement in clinical indicators associated with laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with non-obese type 2 diabetes mellitus (T2DM). METHODS LRYGB was performed in 30 T2DM patients with a BMI <35 kg/m(2). The patients were followed up for 1 year. Pre- and postoperative changes in BMI, waist circumference, and biochemical indicators including fasting plasma glucose and glycosylated hemoglobin were recorded. RESULTS Significant reduction in glycosylated hemoglobin from 8.02 ± 1.77 to 5.59 ± 1.02 % (p < 0.05) at 12 months was noted. Diabetes was completely resolved in nine cases, resulting in discontinuation of diabetes-related medication. No significant surgical complications occurred. CONCLUSIONS LRYGB is beneficial for non-obese T2DM patients in China.
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Affiliation(s)
- Liyong Zhu
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, People's Republic of China
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Bradley D, Magkos F, Klein S. Effects of bariatric surgery on glucose homeostasis and type 2 diabetes. Gastroenterology 2012; 143:897-912. [PMID: 22885332 PMCID: PMC3462491 DOI: 10.1053/j.gastro.2012.07.114] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 07/20/2012] [Accepted: 07/23/2012] [Indexed: 12/19/2022]
Abstract
Obesity is an important risk factor for type 2 diabetes mellitus (T2DM). Weight loss improves the major factors involved in the pathogenesis of T2DM, namely insulin action and beta cell function, and is considered a primary therapy for obese patients who have T2DM. Unfortunately, most patients with T2DM fail to achieve successful weight loss and adequate glycemic control from medical therapy. In contrast, bariatric surgery causes marked weight loss and complete remission of T2DM in most patients. Moreover, bariatric surgical procedures that divert nutrients away from the upper gastrointestinal tract are more successful in producing weight loss and remission of T2DM than those that simply restrict stomach capacity. Although upper gastrointestinal tract bypass procedures alter the metabolic response to meal ingestion, by increasing early postprandial plasma concentrations of glucagon-like peptide 1 and insulin, it is not clear whether these effects make an important contribution to long-term control of glycemia and T2DM once substantial surgery-induced weight loss has occurred. Nonetheless, the effects of surgery on body weight and metabolic function indicate that bariatric surgery should be part of the standard therapy for T2DM. More research is needed to advance our understanding of the physiological effects of different bariatric surgical procedures and possible weight loss-independent factors that improve metabolic function and contribute to the resolution of T2DM.
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Péquignot A, Dhahri A, Verhaeghe P, Desailloud R, Lalau JD, Regimbeau JM. Efficiency of laparoscopic sleeve gastrectomy on metabolic syndrome disorders: two years results. J Visc Surg 2012; 149:e350-5. [PMID: 22809752 DOI: 10.1016/j.jviscsurg.2012.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES There are very few studies evaluating the efficacy of sleeve gastrectomy on the metabolic syndrome, truly a worldwide pandemic. The main objective of this study was to retrospectively determine the evolution of the metabolic syndrome and its associated comorbidities (type 2 diabetes, arterial hypertension, and dyslipidemia) at 24 months after sleeve gastrectomy. The secondary objective was to determine the predictive factors for resolution of this syndrome. MATERIAL AND METHODS Between July 2004 and February 2008, 241 patients with morbid obesity (males: 17%) underwent sleeve gastrectomy in our center. Patients were seen in combined medical and surgical outpatient postoperative follow-up consultation at 3, 6, 12 and 24 months. Patients were classed as responders or not, according to whether or not the metabolic syndrome (as defined according to the National Cholesterol Education Program-Adult Treatment Panel III [NCEP-ATPIII]) disappeared at 24 months follow-up. RESULTS Thirty-six patients (15% of all patients, 30% of males) presented initially with metabolic syndrome. Twenty-six patients (72%) still had metabolic syndrome at 6 months, 17 patients (47%) at 12 months, and 13 patients (36%) at 24 months. The main parameters that regressed after sleeve gastrectomy were type 2 diabetes and hypertriglyceridemia. In univariate analysis, only one parameter (systolic blood pressure) appeared to be a factor of non-resolution of the metabolic syndrome at 24 months. CONCLUSION Our study showed that sleeve gastrectomy reduced the incidence of the metabolic syndrome and several of its components.
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Affiliation(s)
- A Péquignot
- Service de chirurgie digestive et métabolique, CHU Nord, Victor-Pauchet, 80000 Amiens, France
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Obestatin and insulin in pancreas of newborn diabetic rats treated with exogenous ghrelin. Acta Histochem 2012; 114:349-57. [PMID: 21803403 DOI: 10.1016/j.acthis.2011.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 07/06/2011] [Accepted: 07/07/2011] [Indexed: 01/24/2023]
Abstract
The aim of the study was to evaluate the effect of ghrelin treatment on obestatin, insulin gene expression and biochemical parameters in the pancreas of newborn-streptozocin (STZ) diabetic rats. Rats were divided into 4 groups. Group I: control rats treated with physiological saline; group II: control rats treated with 100 μg/kg/day ghrelin; group III: two days after birth rats that received 100mg/kg STZ injected as a single dose to induce neonatal diabetes; group IV: neonatal-STZ-diabetic rats treated with ghrelin for four weeks. Sections of the pancreas were examined with immunohistochemistry for the expression of obestatin and insulin and in situ hybridization for the expression of insulin mRNA. The blood glucose levels were measured. Tissue homogenates were used for protein, glutathione, lipid peroxidation and non-enzymatic glycosylation levels and antioxidant enzyme analysis. There was a significant difference in blood glucose levels in newborn-STZ-diabetic rats compared to ghrelin treated diabetic rats at weeks 1, 2 and 4. In group IV, pancreatic non-enzymatic glycosylation and lipid peroxidation levels were decreased, however, glutathione levels and enzymatic activities were increased. Insulin peptide and mRNA (+) signals in islets of Langerhans and obestatin immunopositive cell numbers showed an increase in group IV compared to group III. These results suggest that administration of ghrelin to newborn rats may prevent effects of diabetes.
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Abstract
Bariatric surgery provides substantial, sustained weight loss and major improvements in glycaemic control in severely obese individuals with type 2 diabetes. However, uptake of surgery in eligible patients is poor, and the barriers are difficult to surmount. We examine the indications for and efficacy and safety of conventional bariatric surgical procedures and their effect on glycaemic control in type 2 diabetes. How surgical gastrointestinal interventions achieve these changes is of great research interest, and is evolving rapidly. Old classifications about restriction and malabsorption are inadequate, and we explore understanding of putative mechanisms. Some bariatric procedures improve glycaemic control in people with diabetes beyond that expected for weight loss, and understanding this additional effect could provide insights into the pathogenesis of type 2 diabetes and assist in the development of new procedures, devices, and drugs both for obese and non-obese patients.
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Affiliation(s)
- John B Dixon
- Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia.
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The preliminary clinical experience with laparoscopic duodenojejunal bypass for treatment of type 2 diabetes mellitus in non-morbidly obese patients: the 1-year result in a single institute. Surg Endosc 2012; 26:3287-92. [PMID: 22678172 DOI: 10.1007/s00464-012-2341-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 04/17/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although various bariatric surgeries are widely known for their effect of ameliorating type 2 diabetes mellitus (T2DM), there are only a few reports demonstrating the effect of duodenojejunal bypass on T2DM. The aim of this study was to evaluate and report the clinical effects of laparoscopic duodenojejunal bypass (LDJB) in non-morbidly obese patients with T2DM. METHODS Twelve non-morbidly obese patients with T2DM underwent LDJB. Changes in fasting blood glucose, body mass index glycosylated hemoglobin (HbA1c), and dose of antidiabetic medications were recorded prospectively during a 1-year period. RESULTS Reduction in HbA1c occurred 3 months after surgery and was maintained up to 1 year, and hyperglycemia was reversed within 1 month after surgery and remained controlled at 12 months. BMI decreased significantly 1 month after surgery and then remained steady through the year. Three patients (25.0 %) stopped antidiabetic medication, seven (58.3 %) patients maintained or decreased doses, and two (16.7 %) increased doses. Seven (58.3 %) patients had a decline in HbA1c. CONCLUSION LDJB demonstrated a glycemic control effect up to 1 year on T2DM in non-morbidly obese patients.
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Klein S, Fabbrini E, Patterson BW, Polonsky KS, Schiavon CA, Correa JL, Salles JE, Wajchenberg BL, Cohen R. Moderate effect of duodenal-jejunal bypass surgery on glucose homeostasis in patients with type 2 diabetes. Obesity (Silver Spring) 2012; 20:1266-72. [PMID: 22262157 PMCID: PMC3619418 DOI: 10.1038/oby.2011.377] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastric bypass surgery causes resolution of type 2 diabetes (T2DM), which has led to the hypothesis that upper gastrointestinal (UGI) tract diversion, itself, improves glycemic control. The purpose of this study was to determine whether UGI tract bypass without gastric exclusion has therapeutic effects in patients with T2DM. We performed a prospective trial to assess glucose and β-cell response to an oral glucose load before and at 6, 9, and 12 months after duodenal-jejunal bypass (DJB) surgery. Thirty-five overweight or obese adults (BMI: 27.0 ± 4.0 kg/m(2)) with T2DM and 35 sex-, age-, race-, and BMI-matched subjects with normal glucose tolerance (NGT) were studied. Subjects lost weight after surgery, which was greatest at 3 months (6.9 ± 4.9%) with subsequent regain to 4.2 ± 5.3% weight loss at 12 months after surgery. Glycated hemoglobin (HbA(1c)) decreased from 9.3 ± 1.6% before to 7.7 ± 2.0% at 12 months after surgery (P < 0.001), in conjunction with a 20% decrease in the use of diabetes medications (P < 0.05); 7 (20%) subjects achieved remission of diabetes (no medications and HbA(1c) <6.5%). The area under the curve after glucose ingestion was ~20% lower for glucose but doubled for insulin and C-peptide at 12 months, compared with pre-surgery values (all P < 0.01). However, the β-cell response was still 70% lower than subjects with NGT (P < 0.001). DJB surgery improves glycemic control and increases, but does not normalize the β-cell response to glucose ingestion. These findings suggest that altering the intestinal site of delivery of ingested nutrients has moderate therapeutic effects by improving β-cell function and glycemic control.
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Affiliation(s)
- Samuel Klein
- Center for Human Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA.
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Reis CEG, Alvarez-Leite JI, Bressan J, Alfenas RC. Role of bariatric-metabolic surgery in the treatment of obese type 2 diabetes with body mass index <35 kg/m2: a literature review. Diabetes Technol Ther 2012; 14:365-72. [PMID: 22176155 DOI: 10.1089/dia.2011.0127] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Bariatric surgery has been used to treat type 2 diabetes mellitus (T2DM); however, its efficacy is still debatable. This literature review analyzed articles that evaluated the effects of bariatric surgery in treatment of T2DM in obese patients with a body mass index (BMI) of <35 kg/m(2). A paired t test was applied for the analysis of pre- and postintervention mean BMI, fasting plasma glucose (FPG), and glycosylated hemoglobin (A1c) values. A significant (P<0.001) reduction in BMI (from 29.95±0.51 kg/m(2) to 24.83±0.44 kg/m(2)), FPG (from 207.86±8.51 mg/dL to 113.54±4.93 mg/dL), and A1c (from 8.89±0.15% to 6.35±0.18%) was observed in 29 articles (n=675). T2DM resolution (A1c <7% without antidiabetes medication) was achieved in 84.0% (n=567) of the subjects. T2DM remission, control, and improvement were observed in 55.41%, 28.59%, and 14.37%, respectively. Only 1.63% (n=11) of the subjects presented similar or worse glycemic control after the surgery. T2DM remission (A1c <6% without antidiabetes medication) was higher after mini-gastric bypass (72.22%) and laparoscopic/Roux-en-Y gastric bypass (70.43%). According to the Foregut and Hindgut Hypotheses, T2DM results from the imbalance between the incretins and diabetogenic signals. The procedures that remove the proximal intestine and do ileal transposition contribute to the increase of glucagon-like peptide-1 levels and improvement of insulin sensitivity. These findings provide preliminary evidence of the benefits of bariatric-metabolic surgery on glycemic control of T2DM obese subjects with a BMI of <35 kg/m(2). However, more clinical trials are needed to investigate the metabolic effects of bariatric surgery in T2DM remission on pre-obese and obese class I patients.
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Affiliation(s)
- Caio E G Reis
- School of Health Sciences, University of Brasília, Brasília, Brazil.
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Li Q, Chen L, Yang Z, Ye Z, Huang Y, He M, Zhang S, Feng X, Gong W, Zhang Z, Zhao W, Liu C, Qu S, Hu R. Metabolic effects of bariatric surgery in type 2 diabetic patients with body mass index < 35 kg/m2. Diabetes Obes Metab 2012; 14:262-70. [PMID: 22051116 DOI: 10.1111/j.1463-1326.2011.01524.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM The aim of this meta-analysis is to assess the metabolic effects of bariatric surgery in type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) < 35 kg/m(2) . METHODS We performed an electronic literature search of published articles to identify relevant evidence since inception to June 2011. Primary outcome measures were metabolic improvement and resolution diabetes after bariatric surgery. The weighted mean difference (WMD) and its 95% confidence interval (CI) were calculated from the raw data extracted from the original literature. The software Review Manager (version 4.3.1) was applied for meta-analysis. RESULTS Thirteen trials involving 357 patients were included in the meta-analysis. The follow-up interval ranged from 6 months to 18 years. According to WMD calculation, bariatric surgery led to 5.18 kg/m(2) of BMI lowering (95% CI, 3.79-6.57, p < 0.00001), 4.8 mmol/l of fasting plasma glucose (FPG) decrement (95% CI, 3.88-5.71 mmol/l, p < 0.00001), 2.59% of HbA1c decreasing (95% CI, 2.12-3.07%, p < 0.00001), 56.67 mg/dl of triglyceride decrement (95% CI 11.53-101.82, p = 0.01) and 48.38 mg/dl of total cholesterol reduction (95% CI 21.08-75.68, p = 0.0005). Moreover, the procedures produced an increased high-density lipoprotein cholesterol by 5.37 mg/dl (95% CI -11.37-0.63, p = 0.08). However, this effect was not statistically significant. Overall, 80.0% of the patients achieved adequate glycaemic control (HbA1c < 7%) without antidiabetic medication. The surgeries produced a low incidence of major complications (3.2%) with no mortality. CONCLUSIONS Bariatric surgery is effectual and safe in the treatment of non-severely obese (BMI < 35 kg/m(2) ) T2DM patients. Moreover, the metabolic benefits acquired from the procedures can be long sustained after the surgery.
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Affiliation(s)
- Q Li
- Institute of Endocrinology and Diabetology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Cohen R, Caravatto PP, Correa JL, Noujaim P, Petry TZ, Salles JE, Schiavon CA. Glycemic control after stomach-sparing duodenal-jejunal bypass surgery in diabetic patients with low body mass index. Surg Obes Relat Dis 2012; 8:375-80. [PMID: 22410638 DOI: 10.1016/j.soard.2012.01.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 01/26/2012] [Accepted: 01/29/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND Bariatric surgery frequently results in the resolution of type 2 diabetes mellitus (T2DM). One of the many factors that could explain such findings is the duodenal exclusion of the alimentary tract. To test this hypothesis, a surgical model that induces glycemic control without significant weight loss would be ideal. In the present study, we evaluated the early metabolic changes that occur in overweight diabetic patients after laparoscopic duodenal-jejunal bypass (DJB) and determined the factors associated with success in T2DM resolution. The setting was a private practice. METHODS A total of 35 patients (20 men and 15 women) were included in the present study. The mean preoperative body mass index was 28.4 ± 2.9 kg/m(2). DJB was performed in all patients, and the anthropometric data and blood samples were collected at baseline (preoperatively) and 3, 6, 9, and 12 months after surgery. Success was defined when patients reached a glycated hemoglobin level of <7% without diabetic medication. RESULTS T2DM remission was observed in 14 (40%) of 35 patients. No differences in the homeostasis model assessment insulin resistance index levels and patient weight were observed before and 12 months after DJB surgery. Gender, duration of T2DM, previous use of insulin, preoperative homeostasis model assessment insulin resistance index, and C-peptide levels were not significant predictive factors of success or nonsuccess. The only factor that significantly predicted postoperative positive outcomes was a waist circumference reduction of ≥ 7% compared with baseline within the first 6 months after surgery. CONCLUSION DJB improves glycemic control; however, it does not increase insulin sensitivity in overweight diabetic patients. These changes were observed without significant weight loss.
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Affiliation(s)
- Ricardo Cohen
- Department of Surgery, Center for Surgical Treatment of Morbid and Metabolic Disorders, Hospital Alemão Oswaldo Cruz, São Paulo, São Paulo, Brazil.
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Shimizu H, Timratana P, Schauer PR, Rogula T. Review of Metabolic Surgery for Type 2 Diabetes in Patients with a BMI < 35 kg/m(2). J Obes 2012; 2012:147256. [PMID: 22720136 PMCID: PMC3375149 DOI: 10.1155/2012/147256] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 03/30/2012] [Indexed: 12/11/2022] Open
Abstract
Bariatric/metabolic surgery is considered an accepted treatment option for type 2 diabetes mellitus (T2DM) with body mass index (BMI) ≧ 35 kg/m(2). Mounting evidence also shows that metabolic surgery is effective for T2DM with BMI < 35 kg/m(2). To evaluate current status of metabolic surgery, we reviewed the available clinical studies which described surgical treatment for T2DM with mean BMI < 35 kg/m(2). 18 studies with 477 patients were identified. 30% of the patients was insulin users. The follow-up period ranged from 6 to 216 months. The weight loss effect was reasonable, not excessive. Mean BMI decreased from 30.4 to 24.8 kg/m(2). Remission of T2DM was achieved in 64.7% of the patients with fasting plasma glucose and glycated hemoglobin approaching slightly above normal range. Clinical T2DM status was an important factor when selecting the eligible candidates for metabolic surgery. Postoperative complication rate of 10.3% with mortality of 0% in the studies has been acceptable. Even though it would be premature at this point to state that metabolic surgery is an accepted treatment option for T2DM with BMI < 35 kg/m(2), it is clear that a high proportion of T2DM patients will derive substantial benefit from metabolic surgery.
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Affiliation(s)
- Hideharu Shimizu
- M61 Cleveland Clinic, Bariatric and Metabolic Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Poochong Timratana
- M61 Cleveland Clinic, Bariatric and Metabolic Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Philip R. Schauer
- M61 Cleveland Clinic, Bariatric and Metabolic Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Tomasz Rogula
- M61 Cleveland Clinic, Bariatric and Metabolic Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA
- *Tomasz Rogula:
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Scalea JR, Cooper M. Surgical strategies for type II diabetes. Transplant Rev (Orlando) 2011; 26:177-82. [PMID: 22115951 DOI: 10.1016/j.trre.2011.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 07/05/2011] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus type II (or type 2 diabetes; DM2) has multiple definitions but is generally considered to be a disease marked by insulin resistance and loss of β cell function that develops in adulthood. Today, greater than 90% of patients with diabetes have DM2. When uncontrolled, DM2 may result in comorbidities such as cardiovascular disease, retinopathy, neuropathy, immune system dysfunction, and renal failure. Classically, treatment of type 2 diabetes has included dietary and lifestyle changes. Even with behavior modification and oral hypoglycemics, many patients are unable to maintain glycemic control. With a growing understanding of the hormonal signals involved in the pathogenesis of type 2 diabetes, there has been a shift in the therapeutic approach to this growing epidemic. Bariatric surgery has been shown to decrease the progression and potentially reverse the effects of diabetes in 80% to 90% of patients. In addition, bariatric operations are associated with sustained weight loss in contrast to nonsurgical options. The antidiabetic effect of bariatric operations is likely due to the improvement in the hormonal dysregulation associated with the development of diabetes. Many patients with diabetes, however, have irreparably damaged insulin production capabilities as well. In addition, it is well recognized that transplantation may be required for patients with severe loss of islet cell function. Surgery for type 2 diabetes, via bariatric procedures and transplantation, has become an important treatment modality for patients with advanced disease.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland, Baltimore, MD, USA.
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Abstract
Published data show that bariatric surgery not only leads to significant and sustained weight loss but also resolves or improves multiple comorbidities associated with morbid obesity. Evidence suggests that the earlier the intervention the better the resolution of comorbidities. Patients with metabolic syndrome and comorbidities associated with morbid obesity should be promptly referred for consideration for bariatric surgery earlier in the disease process.
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Affiliation(s)
- Ashutosh Kaul
- Department of Surgery, Westchester Medical Center, 100 Woods Road PMB 583, Valhalla, NY 10595, USA.
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Metabolic surgery-principles and current concepts. Langenbecks Arch Surg 2011; 396:949-72. [PMID: 21870176 DOI: 10.1007/s00423-011-0834-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 08/01/2011] [Indexed: 12/19/2022]
Abstract
INTRODUCTION In the almost six decades of bariatric surgery, a variety of surgical approaches to treating morbid obesity have been developed. HISTORY AND EVOLUTION Rather than prior techniques being continually superseded by new ones, a broad choice of surgical solutions based on restrictive, malabsorptive, humoral effects, or combinations thereof, is now available. In fact, in recent years, the advent of surgically modifying human metabolism promises new approaches to ameliorate traditionally medically treated metabolic entities, i.e., diabetes, even in the non-obese. The understanding of the various metabolic effects have led to a paradigm shift from bariatric surgery as a solely weight-reducing procedure to metabolic surgery affecting whole body metabolism. CONCLUSION The bariatric surgeon now faces the challenge and opportunity of selecting the most suitable technique for each individual case. To assist in such decision-making, this review, Metabolic surgery-principles and current concepts, is presented, tracing the historical development; describing the various surgical techniques; elucidating the mechanisms by which glycemic control can be achieved that involve favorable changes in insulin secretion and insulin sensitivity, gut hormones, adipokines, energy expenditure, appetite, and preference for low glycemic index foods; as well as exploring the fascinating future potential of this new interdisciplinary field.
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Laparoscopic sleeve gastrectomy with duodenojejunal bypass for the treatment of type 2 diabetes in non-obese patients: technique and preliminary results. Obes Surg 2011; 21:663-7. [PMID: 21336559 DOI: 10.1007/s11695-011-0371-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Medical treatment of type 2 diabetes has often insufficient clinical results at long term. Although the surgical option is a well-established alternative for obese patients, the procedures in non-obese are currently being developed. METHODS A 12-month prospective trial with ten diabetic non-obese patients who underwent laparoscopic sleeve gastrectomy with duodenojejunal bypass is presented. Changes in fasting blood glucose, HbA1c, weight, and BMI were determined. RESULTS There was a significant reduction in fasting glycemia and HbA1c at 1 year postoperative (p < 0.004). One patient had an intra-abdominal bleeding and a wound infection treated with blood transfusion and antibiotic therapy, respectively. The BMI decreased 12.1% and in any case it was reduced to less than 20 kg/m². CONCLUSIONS Laparoscopic sleeve gastrectomy with duodenojejunal bypass is a promising procedure for the treatment of non-obese patients with type 2 diabetes. Studies with large number of patients and longer follow-up are necessary to make definitive conclusions.
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Pories WJ, Mehaffey JH, Staton KM. The surgical treatment of type two diabetes mellitus. Surg Clin North Am 2011; 91:821-36, viii. [PMID: 21787970 DOI: 10.1016/j.suc.2011.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Since the discovery that gastric bypass surgery leads to the rapid reversal of type 2 diabetes mellitus in morbidly obese patients, researchers have been searching for possible mechanisms to explain the result. The significance of bariatric surgery is twofold. It offers hope and successful therapy to the severely obese; those with T2DM, sleep apnea, or polycystic ovary disease; and others plagued by the comorbidities of the metabolic syndrome. This article examines four surgical procedures and their outcomes.
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Affiliation(s)
- Walter J Pories
- Division of Bariatric Surgery, Department of Surgery, The Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Brody Medical Science 4W-48, Mail Stop 639, Greenville, NC 27834, USA.
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Duodenal-jejunal bypass surgery does not increase skeletal muscle insulin signal transduction or glucose disposal in Goto-Kakizaki type 2 diabetic rats. Obes Surg 2011; 21:231-7. [PMID: 21086062 DOI: 10.1007/s11695-010-0304-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Duodenal-jejunal bypass (DJB) has been shown to reverse type 2 diabetes (T2DM) in Goto-Kakizaki (GK) rats, a rodent model of non-obese T2DM. Skeletal muscle insulin resistance is a hallmark decrement in T2DM. The aim of the current work was to investigate the effects of DJB on skeletal muscle insulin signal transduction and glucose disposal. It was hypothesized that DJB would increase skeletal muscle insulin signal transduction and glucose disposal in GK rats. METHODS DJB was performed in GK rats. Sham operations were performed in GK and nondiabetic Wistar-Kyoto (WKY) rats. At 2 weeks post-DJB, oral glucose tolerance (OGTT) was measured. At 3 weeks post-DJB, insulin-induced signal transduction and glucose disposal were measured in skeletal muscle. RESULTS In GK rats and compared to sham operation, DJB did not (1) improve fasting glucose or insulin, (2) improve OGTT, or (3) increase skeletal muscle insulin signal transduction or glucose disposal. Interestingly, skeletal muscle glucose disposal was similar between WKY-Sham, GK-Sham, and GK-DJB. CONCLUSIONS Bypassing of the proximal small intestine does not increase skeletal muscle glucose disposal. The lack of skeletal muscle insulin resistance in GK rats questions whether this animal model is adequate to investigate the etiology and treatments for T2DM. Additionally, bypassing of the foregut may lead to different findings in other animal models of T2DM as well as in T2DM patients.
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Schernthaner G, Brix JM, Kopp HP, Schernthaner GH. Cure of type 2 diabetes by metabolic surgery? A critical analysis of the evidence in 2010. Diabetes Care 2011; 34 Suppl 2:S355-60. [PMID: 21525482 PMCID: PMC3634394 DOI: 10.2337/dc11-s253] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Laparoscopic sleeve gastrectomy with duodenojejunal bypass for severe obesity and/or type 2 diabetes may not require duodenojejunal bypass initially. Obes Surg 2011; 20:1323-4; author reply 1325-6. [PMID: 20411348 DOI: 10.1007/s11695-010-0172-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Fried M, Ribaric G, Buchwald JN, Svacina S, Dolezalova K, Scopinaro N. Metabolic surgery for the treatment of type 2 diabetes in patients with BMI <35 kg/m2: an integrative review of early studies. Obes Surg 2010; 20:776-90. [PMID: 20333558 DOI: 10.1007/s11695-010-0113-3] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Type 2 diabetes mellitus (T2DM) resolution in morbidly obese patients following metabolic surgery suggests the efficacy of T2DM surgery in non-morbidly obese patients (body mass index [BMI] <35 kg/m(2)). This literature review examined research articles in English over the last 30 years (1979-2009) that addressed surgical resolution of T2DM in patients with a mean BMI <35. Weighted and simple means (95% CI) were calculated to analyze study outcomes. Sixteen studies met inclusion criteria; 343 patients underwent one of eight procedures with 6-216 months follow-up. Patients lost a clinically meaningful, not excessive, amount of weight (from BMI 29.4 to 24.2; -5.1), moving from the overweight into the normal weight category. There were 85.3% patients who were off T2DM medications with fasting plasma glucose approaching normal (105.2 mg/dL, -93.3), and normal glycated hemoglobin, 6% (-2.7). In subgroup comparison, BMI reduction and T2DM resolution were greatest following malabsorptive/restrictive procedures, and in the preoperatively mildly obese (30.0-35.0) vs overweight (25.0-25.9) BMI ranges. Complications were few with low operative mortality (0.29%). Novel and/or known mechanisms of T2DM resolution may be engaged by surgery at a BMI threshold <or=30. The majority of low-BMI patients experienced resolution of laboratory and clinical manifestations of T2DM without inappropriate weight loss.
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Affiliation(s)
- M Fried
- Centre for Treatment of Obesity and Metabolic Disorders, OB klinika, Pod Krejcarkem 975, 130 00, Prague 3, Czech Republic.
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Harvey EJ, Arroyo K, Korner J, Inabnet WB. Hormone Changes Affecting Energy Homeostasis after Metabolic Surgery. ACTA ACUST UNITED AC 2010; 77:446-65. [DOI: 10.1002/msj.20203] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Arroyo K, Kini SU, Harvey JE, Herron DM. Surgical Therapy for Diabesity. ACTA ACUST UNITED AC 2010; 77:418-30. [DOI: 10.1002/msj.20209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Demaria EJ, Winegar DA, Pate VW, Hutcher NE, Ponce J, Pories WJ. Early postoperative outcomes of metabolic surgery to treat diabetes from sites participating in the ASMBS bariatric surgery center of excellence program as reported in the Bariatric Outcomes Longitudinal Database. Ann Surg 2010; 252:559-66; discussion 566-7. [PMID: 20739857 DOI: 10.1097/sla.0b013e3181f2aed0] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Small case series suggest bariatric surgery may be an effective treatment for type 2 diabetes mellitus in patients who do not meet body weight criteria for morbid obesity (body mass index [BMI], <35 kg/m), but large multi-institutional series, which allow better assessment of the safety and efficacy of treatment, have not been reported. METHODS Data from 66,264 research-consented patients with a primary bariatric surgery encounter in the Bariatric Outcomes Longitudinal Database from June 2007 to June 2009 were queried to identify patients with a BMI > or =30 but <35 kg/m2 (1.2%, n = 794) and diabetes requiring any medication (29%). RESULTS A total of 235 patients met inclusion criteria. The 2 most common procedures, adjustable gastric banding (n = 109) and gastric bypass (n = 109), were compared. Laparoscopic access was used in 92% of procedures. Gender (76.6% female), race (80.4% White), and age (mean 52.6 +/- 10.4 years) did not differ between procedure groups. Gastric bypass provided superior weight loss and diabetes remission but demonstrated more frequent complications (90-day complications: 18% vs. 3%, P < 0.05). No mortalities were reported, and most complications were minor. CONCLUSIONS The data suggest early effectiveness of surgical treatment of diabetes in patients who do not meet criteria for morbid obesity. Gastric bypass provides more effective treatment for diabetes than adjustable gastric banding within 6 to 12 months.
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Rubino F, Schauer PR, Kaplan LM, Cummings DE. Metabolic surgery to treat type 2 diabetes: clinical outcomes and mechanisms of action. Annu Rev Med 2010; 61:393-411. [PMID: 20059345 DOI: 10.1146/annurev.med.051308.105148] [Citation(s) in RCA: 267] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Several gastrointestinal (GI) operations that were designed to promote weight loss can powerfully ameliorate type 2 diabetes mellitus (T2DM). Although T2DM is traditionally viewed as a chronic, relentless disease in which delay of end-organ complications is the major treatment goal, GI surgery offers a novel endpoint: complete disease remission. Ample data confirm the excellent safety and efficacy of conventional bariatric operations-especially Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding-to treat T2DM in severely obese patients. Use of experimental procedures as well as conventional bariatric operations is increasingly being explored in less obese diabetic patients, with generally favorable results, although further assessment of risk:benefit profiles is needed. Mounting evidence indicates that certain operations involving intestinal diversions improve glucose homeostasis through varied mechanisms beyond reduced food intake and body weight, for example by modulating gut hormones. Research to elucidate such mechanisms should facilitate the design of novel pharmacotherapeutics and dedicated antidiabetes GI manipulations. Here we review evidence regarding the use and study of GI surgery to treat T2DM, focusing on available published reports as well as results from the Diabetes Surgery Summit (DSS) in Rome and the World Congress on Interventional Therapies for T2DM in New York City.
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Affiliation(s)
- Francesco Rubino
- Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York, USA.
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Rubino F, R'bibo SL, del Genio F, Mazumdar M, McGraw TE. Metabolic surgery: the role of the gastrointestinal tract in diabetes mellitus. Nat Rev Endocrinol 2010; 6:102-9. [PMID: 20098450 PMCID: PMC2999518 DOI: 10.1038/nrendo.2009.268] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Several conventional methods of bariatric surgery can induce long-term remission of type 2 diabetes mellitus (T2DM); novel gastrointestinal surgical procedures are reported to have similar effects. These procedures also dramatically improve other metabolic conditions, including hyperlipidemia and hypertension, in both obese and nonobese patients. Several studies have provided evidence that these metabolic effects are not simply the results of drastic weight loss and decreased caloric intake but might be attributable, in part, to endocrine changes resulting from surgical manipulation of the gastrointestinal tract. In this Review, we provide an overview of the clinical evidence that demonstrates the effects of such interventions-termed metabolic surgery-on T2DM and discuss the implications for future research. In light of the evidence presented here, we speculate that the gastrointestinal tract might have a role in the pathophysiology of T2DM and obesity.
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Affiliation(s)
- Francesco Rubino
- Section of Gastrointestinal Metabolic Surgery, Department of Surgery, Weill Cornell Medical College/New York Presbyterian Hospital, 525 East 68th Street, P-714, New York, NY 10065, USA.
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