Clinical Course of Diabetes After Gastrectomy According to Type of Reconstruction in Patients with Concurrent Gastric Cancer and Type 2 Diabetes

The Metabolic Effects and Effectiveness of the Different Reconstruction Methods used in Gastric Cancer Surgery: A Systematic Review and Meta-Analysis

Gastric Cancer (GC) is the fifth most common cancer worldwide. Early stages of GC began being detected, giving rise to a new concern, Quality of Life. This study aimed to systematically assess the effects of different GC reconstruction techniques on postoperative type 2 diabetes mellitus (T2DM), hypertension (HBP), and body mass index (BMI) reduction rate and to provide an overview of recent research on oncometabolic surgery (OS). We performed a systematic review and meta-analysis by searching three databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed a meta-analysis of risk ratios and mean differences to estimate the impact of duodenal bypass, Roux-en-Y reconstruction, and residual stomach on T2DM, HBP, and BMI reduction rate. Heterogeneity was assessed using the I2 statistics. At the end of the follow-up, the duodenal bypass group compared to Billroth I had a significantly higher postoperative remission of T2DM and HBP, with a relative risk (RR) of 1.43 (95% confidence interval (95% CI) [1.27; 1.62]) and 1.3 (95% CI [1.00; 1.69]), respectively. Compared with the Billroth II group, Roux-en-Y reconstruction had significantly greater T2DM remission after gastrectomy (RR = 1.19; 95% CI [1.08; 1.31]), while HBP showed no significant differences. Regarding the improvement of HBP, total gastrectomy was significantly superior to subtotal gastrectomy (95% CI [1.01; 2.64]). A trend towards Roux-en-Y Esophagojejunostomy as the best option for T2DM remission was observed (95% CI [0.98; 2.77]; p = 0.06). Gastrectomy with Roux-en-Y reconstruction appears to be the most effective treatment for T2DM remission. Further research is needed to assess the impact of OS on metabolic diseases.

Metabolic effects of truncal vagotomy when combined with bariatric-metabolic surgery

Bariatric-metabolic surgery (BMS) in patients with obesity frequently leads to remission of concurrent type 2 diabetes mellitus (T2DM), even before body weight loss takes place. This is probably based on the correction of a dysmetabolic cycle in the gastrointestinal physiology of T2DM that includes increased vagus-dependent exocrine pancreatic secretion (EPS) and, hence, amplified digestion and nutrient absorption. The resultant chronic exposure of tissues to high plasma levels of glucose, fatty acids and amino acids causes tissue resistance to the actions of insulin and, at a later stage, β-cell dysfunction and reduction of insulin release. We hypothesize that the addition of a surgical truncal vagotomy (TV) may improve and solidify the beneficial results of BMS on T2DM by stably decreasing EPS, - hence reducing the digestion and absorption of nutrients -, and increasing incretin secretion as a result of increased delivery of unabsorbed nutrients to the distal intestine. This hypothesis is supported by surgical data from gastrointestinal malignancies and peptic ulcer operations that include TV, as well as by vagal blockade studies. We suggest that TV may result in a stable reduction of EPS, and that its combination with the appropriate type of BΜS, may enhance and sustain the salutary effects of the latter on T2DM.

Oncometabolic surgery in gastric cancer patients with type 2 diabetes

The rates of early gastric cancer and type 2 diabetes mellitus(T2DM) are sharply increasing in Korea. Oncometabolic surgery in which metabolic surgery is conducted along with cancer surgery is a method used to treat gastric cancer and T2DM in one-stage operation. From 2011 to 2019, a total of 48 patients underwent long-limb Roux-en-Y gastrectomy (LRYG) in Inha University Hospital, and all data were reviewed retrospectively. A 75 g oral glucose tolerance test and serum insulin level test were performed before and 1 week and 1 year after surgery. One year after LRYG operation, 25 of 48 patients showed complete or partial remission and 23 patients showed non-remission of T2DM. The preoperative HbA1c level was significantly lower and the change in HbA1c was significantly greater in the T2DM remission group. Insulin secretion indices(insulinogenic index and disposition index) were increased significantly in the T2DM remission group. In contrast, the insulin resistance indices (homeostatic model assessment of insulin resistance (HOMA-IR) and Matsuda index) changed minimal. In the case of LRYG in T2DM patients, remnant β cell function is an important predictor of favorable glycemic control.

Impact of Preoperative Type 2 Diabetes Mellitus on the Outcomes of Gastric Cancer Patients Following Gastrectomy: A Propensity Score Matching Analysis

Purpose

The current study aims to explore the outcomes of type 2 diabetes mellitus (T2DM) on gastric cancer patients following gastrectomy through propensity score matching (PSM) analysis.

Methods

A retrospective study of gastric cancer patients following gastrectomy was conducted in a single clinical center from January 2014 to December 2019. The short-term outcomes, overall survival (OS) and disease-free survival (DFS) were analyzed between T2DM group and Non-T2DM group.

Results

A total of 703 patients were enrolled in this study. After 1:1 PSM, 84 patients in T2DM group and 84 patients in Non-T2DM were matched for final analysis. No significant difference was found in terms of operation time, intra-operative blood loss, retrieved lymph nodes, postoperative stay, blood transfusion and complications between T2DM group and Non-T2DM group (p > 0.05). The Kaplan-Meier curve implied that T2DM had no impact on OS or DFS. Cox regression was conducted to identify predictive factors for prognosis. Body mass index (BMI) (p = 0.039 < 0.05, HR = 0.725, 95% CI = 0.534–0.983), pre-operative lymphocyte (p = 0.017 < 0.05, HR = 0.678, 95% CI = 0.493–0.932), pathological tumor node metastasis (pTNM) stage (p = 0.000 < 0.05, HR = 2.619, 95% CI = 2.048–3.349) and complications (p = 0.006 < 0.05, HR = 1.528, 95% CI = 1.132–2.061) were predictive factors for OS, and BMI (p = 0.013 < 0.05, HR = 0.524, 95% CI = 0.315–0.872), pTNM stage (p = 0.000 < 0.05, HR = 2.619, 95% CI = 2.048–3.349) and complications (p = 0.008 < 0.05, HR = 1.892, 95% CI = 1.179–3.036) were independent predictive factors for DFS.

Conclusion

T2DM did not have an impact on gastric cancer patients following gastrectomy in terms of short-term outcomes and prognosis.

Effect of oncometabolic surgery on gastric cancer: The remission of hypertension, type 2 diabetes mellitus, and beyond

This review summarizes the definition and surgical methods of oncometabolic surgery according to previous studies. Then, the authors discuss the beneficial effects observed after gastrectomy in gastric cancer (GC) patients with concurrent hypertension or type 2 diabetes mellitus (T2DM). The authors summarize the current studies analyzing the remission rate and the hypotheses of the mechanisms underlying these effects. The remission rate ranged from 42.5%-65.4% in T2DM patients and from 11.1%-57.6% among those with hypertension. Furthermore, the remission of T2DM could have an impact on overall survival rates as well. The mechanisms underlying the remission of hypertension and T2DM is unclear in current studies, but oncometabolic surgery is expected to be applied in clinical practice. In addition, the effect of oncometabolic surgery on other chronic metabolic comorbidities is expected to be proven in further studies. Therefore, the purpose of this review is to discuss the effects of oncometabolic surgery reported in current studies with a primary focus on the remission of hypertension and T2DM after gastrectomy in GC patients. The possibility of the remission of other metabolic comorbidities in GC patients who undergo oncometabolic surgery is also discussed.

Improvement of Diabetes Mellitus After Colorectal Cancer Surgery: A Retrospective Study of Predictive Factors For Type 2 Diabetes Mellitus Remission and Overall Survival

PURPOSE

The purpose of the current study was to evaluate the impact of colorectal cancer (CRC) surgery on type 2 diabetes mellitus (T2DM) and to analyze the change in T2DM on overall survival after CRC surgery.

METHODS

Patients who underwent CRC surgery were retrospectively enrolled from January 2013 to December 2019. The status of T2DM pre- and 1-year after CRC surgery was recorded, and predictive factors for T2DM remission and overall survival were analyzed.

RESULTS

A total of 296 patients were included in this study. Thirty-eight patients experienced remission of T2DM 1 year after CRC surgery, and the remission rate was 12.8%. Weight loss was significantly higher in the T2DM remission group (p = 0.038), and the T2DM duration was significantly shorter in the T2DM remission group (p = 0.015). In the multivariate logistic regression analysis, higher weight loss (p = 0.046, odds ratio = 1.060, 95% CI = 1.001-1.122) and shorter T2DM duration (p = 0.019, odds ratio = 1007, 95% CI = 1.001-1.014) were predictive factors for remission of T2DM. Furthermore, in multivariate Cox regression analysis, lower TNM stage (p = 0.000, odds ratio = 2.147, 95% CI = 1.474-3.128) and T2DM remission (p = 0.033, odds ratio = 2.999, 95% CI = 1.091-8.243) were the predictive factors for better overall survival.

CONCLUSION

Patients with concurrent CRC and T2DM had a 12.8% remission 1 year after CRC surgery. Higher weight loss and shorter T2DM duration contributed to T2DM remission, and patients with T2DM remission could improve in terms of their overall survival.

Predictors of Remission and Relapse of Diabetes after Conventional Gastrectomy for Gastric Cancer: Nationwide Population-Based Cohort Study

BACKGROUND

We investigated whether preoperative clinical parameters predict diabetes remission and relapse after conventional gastrectomy for cancer and whether postoperative weight changes influence diabetes remission and relapse.

STUDY DESIGN

This study included 5,150 patients with diabetes who underwent gastrectomy for cancer from 2004 to 2014. Diabetes remission was defined in 3 ways, according to postoperative antidiabetic medication and fasting plasma glucose (FPG) levels. Diabetes relapse was defined as reinitiating antidiabetic medication among patients in diabetes remission.

RESULTS

Six predictors (higher body mass index [BMI], total gastrectomy, younger age, FPG levels, number of oral hypoglycemic agents [OHAs], and no insulin use) of diabetes remission increased the likelihood of remission by >13-fold (odds ratio [OR], 13.67; 95% confidence interval [CI], 8.65‒19.11). Three factors (younger age, lower FPG levels, and use of only 1 OHA) predicted a 58% decreased likelihood of diabetes relapse (hazard ratio, 0.42; 95% CI 0.35‒0.48). The lowest interval of postoperative BMI decrease (<-20%) showed a >3-fold increased likelihood of diabetes remission than the highest interval (≥-5%; OR 3.14; 95% CI 2.08‒4.75), independent of baseline BMI.

CONCLUSIONS

Six variables (BMI, type of gastrectomy, age, FPG levels, number of OHAs used, and insulin use/non-use), and 3 variables (age, FPG levels, number of OHAs used) significantly predict diabetes remission and relapse after gastrectomy for cancer, respectively. Greater postoperative weight decrease may increase the likelihood of diabetes remission, independent of baseline weight. Our results may serve as a basis for the establishment of diabetes and weight management strategies after conventional gastrectomy for cancer.

Does Roux-en-Y Construction Really Bring Benefit of Type 2 Diabetes Mellitus Remission After Gastrectomy in Patients with Gastric Cancer? A Systematic Review and Meta-Analysis

INTRODUCTION

To evaluate whether the extent of gastrectomy or the reconstruction method brings benefit of type 2 diabetes mellitus (T2DM) remission after gastrectomy in patients with gastric cancer.

METHODS

PUBMED, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched to find eligible studies published from inception to July 31, 2020.

RESULTS

A total of nine studies (1424 patients) were included. At the first year and the end of follow-up time after gastrectomy, the total gastrectomy group had better T2DM remission than the subtotal gastrectomy group, and the Roux-en-Y reconstruction (R-Y) group had better T2DM remission compared with the non-R-Y group. There was no difference between R-Y and non-R-Y in terms of subtotal gastrectomy (OR 1.08, 95% CI 0.63-1.84, P = 0.78). However, total gastrectomy with R-Y had better T2DM remission than subtotal gastrectomy with R-Y (OR 2.75, 95% CI 1.19-6.35, P = 0.02).

CONCLUSION

Total gastrectomy with R-Y had better T2DM remission. The extent of gastrectomy rather than the reconstruction method might play an important role in T2DM remission after gastrectomy in patients with gastric cancer.

Onco-Metabolic Surgery: A Combined Approach to Gastric Cancer and Hypertension

Purpose

The purpose of this study was to explore the changes in blood pressure in patients with concurrent gastric cancer and hypertension after gastrectomy, and to identify the factors that affect the changes in blood pressure.

Materials and Methods

Patients with concurrent gastric cancer and hypertension who underwent gastrectomy were retrospectively analyzed from January 2013 to December 2018. The pre- and 6-month postoperative medical records were compared. Predictors for the remission of hypertension were analyzed.

Results

A total of 143 patients with concurrent gastric cancer and hypertension were included in this study. The number of patients with complete remission, partial remission and no remission were 67 (46.9%), 12 (8.4%) and 64 (44.7%), respectively. The average of weight and BMI (body mass index) before gastrectomy were 63.0 ± 9.7 kg and 23.4 ± 2.9 kg/m², respectively, which were significantly higher than those 6-month postgastrectomy: 54.8 ± 9.8 kg and 20.4 ± 3.1 kg/m², respectively (p<0.001). The average number of antihypertensive medications before gastrectomy was 1.5 ± 0.6, while it was 0.8 ± 0.8 6-month postgastrectomy (p<0.001). Age (p<0.05) and the surgical techniques used (p<0.05) were significantly different between partial remission and no remission patients. Furthermore, age (p<0.05) and the surgical techniques used (p<0.05) were significantly different between complete remission and no remission patients. Age (p<0.05, odds ratio =0.933, 95% CI=0.890–0.978) and the surgical techniques used (p<0.05, odds ratio =2.749, 95% CI=1.132–6.677) are predictors for remission of hypertension.

Conclusion

Total gastrectomy is an onco-metabolic surgery that can cure younger patients with concurrent gastric cancer and hypertension. Age and the surgical techniques used can predict the remission of hypertension 6 months after gastrectomy.

Does Reconstruction Type After Gastric Resection Matters for Type 2 Diabetes Improvement?

BACKGROUND

Gastrointestinal (GI) surgery involving gastric resection and bypass of intestinal segments was reported to facilitate glucose control in obese patients with type 2 diabetes (T2D).

AIM

Our aim was to assess whether the type of post-gastrectomy GI reconstruction also influences glucose control in T2D patients with BMI below 35 kg/m² submitted to gastrointestinal surgery without bariatric intention.

METHODS

A cohort of T2D Caucasian patients (n = 40) with upper GI malignancy (n = 33) or complicated reflux disease (n = 7) were submitted to either a gastrectomy plus Billroth II (BII) gastrojejunal anastomosis (n = 17), a gastrectomy plus Roux-en-Y gastrojejunostomy (RY) reconstruction (n = 18; subtotal gastrectomy n = 7 and total gastrectomy n = 11), or atypical gastrectomy without reconstruction (no-R) (n = 5). Patients were evaluated before and 2 years after surgery for body weight, Hb1Ac, need of glucose lowering drugs, and presence of diabetes.

RESULTS

Body mass index (BMI) decreased after every surgical procedure when compared to baseline (- 0.9 ± 0.8 kg/m² for BII vs - 4.3 ± 2.6 kg/m² for RY vs - 4.6 ± 2.5 kg/m² for no-R, p < 0.05), which was only significantly different after RY surgeries. Diabetes remission occurred in 5.9% of BII patients, in 27.8% of RY patients, and 0% of no-R patients, while in patients with persistent T2D, the needs for glucose-lowering drugs were significantly also decreased after RY (31.3% BII vs 66.7% RY vs 25% no-R, p = 0.03).

CONCLUSIONS

T2D Caucasian patients undergoing post-gastrectomy GI reconstructions without a bariatric intention experience a significant improvement of T2D, in a magnitude that could be influenced by the technical procedure performed in favor of RY reconstruction. Thus, presence of T2D should be taken into consideration when deciding for the type of post-gastrectomy GI reconstruction.

Oncometabolic surgery: Emergence and legitimacy for investigation

Studies on morbid obesity have shown remarkable improvement of diabetes in patients who have undergone bariatric operations. It was subsequently shown that these operations induce diabetes remission independent of the resultant weight loss; as a result, surgeons began to investigate whether operations for gastric cancer (GC) could have the same beneficial effect on diabetes as bariatric operations. It was then shown in multiple reports that followed that certain operations for GC were able to improve or even cure type 2 diabetes mellitus (T2DM) in GC patients. This finding gave rise to the concept of “oncometabolic surgery”, in which a patient diagnosed with both GC and T2DM undergo a single operation with the purpose of treating both diseases. With the increasing incidence of T2DM, oncometabolic surgery has the potential to improve the quality of life and even extend survival of many GC patients. However, because the GC patient population and the bariatric patient population are wildly different and because different GC operations have different properties, the effect of oncometabolic surgery must be carefully assessed and engineered in order to maximize benefit and avoid harm. This manuscript aims to summarize the findings made so far in the field of oncometabolic surgery and to provide an outlook regarding the possibility of oncometabolic surgery being incorporated into standard clinical practice.

Comparison of Quality of Life and Nutritional Status of Between Roux-en-Y and Billroth-I Reconstruction After Distal Gastrectomy: A Systematic Review and Meta-Analysis

Background: This paper purports to use a meta-analysis to compare the postoperative quality of life (QoL) and nutritional status of between Roux-en-Y (R-Y) and Billroth-I (B-I) reconstruction after distal gastrectomy.Methods: For this study, the following databases were searched for articles published from inception until December 2018: PubMed, Web of Science, EBSCO, and Cochrane library.Results: A total of 13 eligible studies, covering 3645 patients, were selected for a meta-analysis. The analysis showed that compared with B-I group in term of short-term outcomes, patients undergoing R-Y reconstruction did not only have significantly better physiological function (P = 0.02), but had significantly less pain (P = 0.04). In the long-term outcomes, the dyspnea and constipation in the B-I group were worse than that in the R-Y group (P = 0.004; P = 0.04, respectively). Patients in the B-I group had higher cholesterol than those in the R-Y group at 5 years postoperatively (P = 0.003). There were no significant differences in termof other nutritional indicators including total protein, cholesterol, albumin, hemoglobin and weight in short-term outcomes.Conclusions: The final conclusion was that R-Y may be superior to the B-I reconstruction in some aspects of QoL. Besides, R-Y reconstruction could reduce the patient's cholesterol level for a long time. For the short-term outcomes, there were no significant differences in other common nutritional indicators.

Bypassed and Preserved Stomach Resulted in Superior Glucose Control in Sprague-Dawley Rats with Streptozotocin-Induced Diabetes

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.

Nutritional safety of oncometabolic surgery for early gastric cancer patients: a prospective single-arm pilot study using a historical control group for comparison

BACKGROUND

Oncometabolic surgery (OS) is a modification of the Roux-en Y reconstruction method, in which the lengths of the biliopancreatic and Roux limbs are longer than that with conventional surgery (CS). Although OS is performed to improve postoperative glycemic control in gastric cancer patients with type 2 diabetes mellitus (T2DM), its postoperative nutritional safety has not been clarified. This prospective pilot study evaluated the safety and feasibility of OS in early gastric cancer patients.

METHODS

This study evaluated 20 patients with clinical T1N0 stage and preoperative body mass index (BMI) ≥ 32.5 kg/m², or ≥ 27.5 kg/m² with comorbidities, who underwent OS. Primary outcomes were cumulative incidences of anemia and deficiencies in iron and vitamin B12 after 1 year. The outcomes were compared to those of a matched historical control group.

RESULTS

The cumulative incidences of anemia (15.0% vs. 10.0%, P = 0.99), iron deficiency (15.0% vs. 10.0%, P = 0.99), and vitamin B12 deficiency (10.0% vs. 0%, P = 0.47) did not differ significantly in the OS and CS groups. However, median vitamin B12 concentration tended to be lower (395.8 vs. 493.7 pg/mL, P = 0.06) and reductions in vitamin B12 concentration tended to be greater (174.7 vs. 123.0 pg/mL, P = 0.07) in the OS group. BMI loss was similar in the two groups (2.9 vs. 2.8 kg/m², P = 0.80). Remission rates of hypertension (68.8% vs. 41.2%, P = 0.22) and T2DM (77.8% vs. 50.0%, P = 0.58) were higher in the OS group.

CONCLUSION

Nutritional parameters did not differ significantly in the OS and CS groups. Vitamin B12 levels should be carefully monitored after OS.

Effect and Mechanisms of Diabetes Resolution According to the Range of Gastric Resection and the Length of Anastomosis in Animal Models: Implication for Gastric Cancer Surgery in Patients with Diabetes Mellitus

BACKGROUND

To examine the effect and mechanism of Roux-en-Y gastric bypass (RYGB) on the improvement of diabetes according to the length of anastomosis and the gastric pouch volume in an animal model.

METHODS

Glucose intolerance was induced with a high-fat diet for 3 months in Sprague-Dawley rats. The animals were subjected to conventional RYGB (cRYGB; 5% gastric pouch with 15-cm Roux limb, 40-cm biliopancreatic limb; n = 9), short-limb RYGB (sRYGB; 5%, 8, 4 cm; n = 9), fundus-sparing RYGB (fRYGB; 30%, 8, 4 cm; n = 9), or sham operation (n = 9). After 6 weeks, oral glucose tolerance tests (OGTTs) were performed, and gut hormones including insulin, total GLP-1, GIP, and ghrelin were analyzed.

RESULTS

The cRYGB group showed significantly decreased food intake, body weight, and random glucose (p < 0.05). sRYGB resulted in a similar change of body weight loss to that of cRYGB, but with no improvement of hyperglycemia. The fRYGB group showed similar changes of body weight and random glucose to those of the sham group. In cRYGB and sRYGB, the level of insulin steeply increased until 30 min during OGTT. GLP-1 was higher at 30 min in cRYGB than in other groups, without significance. The fRYGB group showed a slowly increasing pattern in OGTT and GLP-1, and the lowest peak point in insulin and GIP.

CONCLUSION

cRYGB with 95% gastric resection was needed to achieve not only weight loss but also diabetes improvement, which could be related to the increase in GLP-1.