Impact of bariatric surgery on type 2 diabetes

Differential unfolded protein response in skeletal muscle from non-diabetic glucose tolerant or intolerant patients with obesity before and after bariatric surgery

AIMS

Not all people with obesity become glucose intolerant, suggesting differential activation of cellular pathways. The unfolded protein response (UPR) may contribute to the development of insulin resistance in several organs, but its role in skeletal muscle remains debated. Therefore, we explored the UPR activation in muscle from non-diabetic glucose tolerant or intolerant patients with obesity and the impact of bariatric procedures.

METHODS

Muscle biopsies from 22 normoglycemic (NG, blood glucose measured 120 min after an oral glucose tolerance test, G120 < 7.8 mM) and 22 glucose intolerant (GI, G120 between 7.8 and 11.1 mM) patients with obesity were used to measure UPR activation by RTqPCR and western blot. Then, UPR was studied in biopsies from 7 NG and 7 GI patients before and 1 year after bariatric surgery.

RESULTS

Binding immunoglobulin protein (BIP) protein was ~ 40% higher in the GI compared to NG subjects. Contrastingly, expression of the UPR-related genes BIP, activating transcription factor 6 (ATF6) and unspliced X-box binding protein 1 (XBP1u) were significantly lower and C/EBP homologous protein (CHOP) tended to decrease (p = 0.08) in GI individuals. While BIP protein positively correlated with fasting blood glucose (r = 0.38, p = 0.01), ATF6 and CHOP were associated with G120 (r = - 0.38 and r = - 0.41, p < 0.05) and the Matsuda index (r = 0.37 and r = 0.38, p < 0.05). Bariatric surgery improved metabolic parameters, associated with higher CHOP expression in GI patients, while ATF6 tended to increase (p = 0.08).

CONCLUSIONS

CHOP and ATF6 expression decreased in non-diabetic GI patients with obesity and was modified by bariatric surgery. These genes may contribute to glucose homeostasis in human skeletal muscle.

Therapeutic Effects of Sleeve Gastrectomy and Ileal Transposition on Type 2 Diabetes in a Non-Obese Rat Model by Regulating Blood Glucose and Reducing Ghrelin Levels

Background

Nowadays, more than 170 million patients suffer from diabetes mellitus worldwide. This study aimed to investigate the effects of sleeve gastrectomy (SG) and ileal transposition (IT) surgery on the control of diabetes.

Material/Methods

Goto-Kakizaki rats were used to establish type 2 diabetes models and undergo SG or IT surgery. At 2 months post-surgery, insulin, glucose, triglycerides (TG), total cholesterol (TC), glucose tolerance, glucagon-like peptide-1 (GLP-1) levels, and insulin sensitivity were evaluated.

Results

SG significantly shortened operative time and post-operative recovery time compared to IT surgery (P<0.05). SG and IT surgery resulted in significantly induced weight loss, significantly decreased levels of glucose, and significantly enhanced levels of Ghrelin compared the Sham surgery group (P<0.001). SG and IT surgery resulted in significantly increased GLP-1 levels compared to Sham surgery (P<0.001). SG resulted in better reduction of oral glucose tolerance test (OGTT) glucose compared to IT surgery (P<0.05). SG and IT surgery significantly upregulated insulin tolerance test (ITT) levels compared to Sham surgery (P<0.001). SG induced better reductions in TC and TG compared to IT surgery (P<0.05).

Conclusions

In non-obese rats with spontaneous diabetes, both SG and IT surgery were found to control diabetes by regulating body weight and levels of glucose, Ghrelin, GLP-1, OGTT glucose, insulin, TC, and TG. Moreover, SG demonstrated advantages of shorter operative time, shorter post-operative recovery time, and better control of diabetes compared to IT surgery.

Recognition and management of hyperinsulinemic hypoglycemia after bariatric surgery

Hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass (RYGB) due to the changes in gut hormonal milieu. Physicians should be aware of this complication to ensure timely and effective treatment of post-RYGB patients, who present to them with hypoglycemic symptoms. Possible causes of hypoglycemia in these patients include late dumping syndrome, nesidioblastosis and rarely insulinoma. Systematic evaluation including history, biochemical analysis, and diagnostic testing might help in distinguishing among these diagnoses. Continuous glucose monitoring is also a valuable tool, revealing the episodes in the natural environment and can also be used to monitor treatment success. Treatment should begin with strict low carbohydrate diet, followed by medication therapy. Therapy with diazoxide, acarbose, calcium channel blockers and octreotide have been proven to be beneficial, but the response apparently is highly variable. When other treatment options fail, surgical options can be considered.

Impact of roux-en Y gastric bypass surgery on prognostic factors of type 2 diabetes mellitus: meta-analysis and systematic review

Our aim is to clarify the features of complete type 2 diabetes mellitus (T2DM) remission in patients who undergo Roux-en Y gastric bypass surgery, to better determine factors affecting the outcome of T2DM surgery. A search was conducted for original studies on Medline, PubMed and Elsevier from inception until October 28, 2014. All of the articles included in this study were assessed with the application of predetermined selection criteria and were divided into two groups: Roux-en Y gastric bypass surgery for T2DM patients in remission or non-remission. The meta-analysis results demonstrated that fasting C-peptide values were significantly associated with increased remission (C-peptide: 95%CI = 0.2-1.0) whereas T2DM duration, patient age, preoperative insulin use, preoperative fasting blood glucose values and preoperative glycosylated haemoglobin values were significantly associated with reduced remission (T2DM duration: 95%CI = -1.2 - -0.7; age: 95%CI = -0.5 - -0.1; percentage of preoperative insulin users: odd ratio = 0.10, 95%CI = 0.07-0.15; preoperative fasting blood glucose: 95%CI = -0.9 - -0.5; preoperative glycosylated haemoglobin: 95%CI = -1.1 - -0.4). However, the results demonstrated that body mass index was not statistically different (body mass index: 95%CI = -0.2-0.6). The results of the systematic review demonstrated that smaller waist circumference; lower total cholesterol, triglycerides and low-density lipoprotein levels, increased higher high-density lipoprotein levels, shorter cardiovascular disease history and less preoperative prevalence of hypertension contribute to the increased postoperative remission rate. Better results are obtained in younger patients with less severe diabetes, a smaller waist circumference, higher preoperative high-density lipoprotein, lower preoperative total cholesterol, triglycerides and low-density lipoprotein levels and fewer other complications of shorter durations.

A prospective evaluation of the influence of three bariatric procedures on insulin resistance improvement. Should the extent of undiluted bile transit be considered a key postoperative factor altering glucose metabolism?

INTRODUCTION

Insulin resistance (IR), the essential step in development of type 2 diabetes mellitus (T2DM), resolves quickly after bariatric surgery, but the effectiveness depends on the type of the procedure. Although the long-term influence on IR improvement is well documented, the mechanisms of the ultra-fast response after restrictive and bypass procedures require explanation.

AIM

To determine IR evolution from the initial preparative period to 6 months after the operation, exposing the rapid postoperative response while comparing the 3 bariatric methods, with the belief that the metabolic effect may be correlated with anatomical combinations.

MATERIAL AND METHODS

From January to December, 2013, a cohort of severely obese, insulin resistant individuals recruited to the prospective study underwent laparoscopic sleeve gastrectomy (SG-30), Roux-en-Y gastric bypass (RYGB-30) and one-anastomosis gastric bypass (OAGB-30). Main laboratory parameters of glucose metabolism were evaluated in fasting patients preoperatively, 4 days and 1, 3 and 6 months after surgery.

RESULTS

Within the whole observation period the most significant improvement in homeostasis model assessment for IR (HOMA-IR) was observed in the first 4 days after each operation. The decrease of HOMA-IR was higher (p < 0.0001) in gastric bypass groups than in patients after SG (-41%). The difference between bypass groups favors OAGB over RYGB (63 vs. -56%, p = 0.0489).

CONCLUSIONS

Among all bariatric management factors, operation type is the most important in IR improvement. The significant difference in response after SG vs. RYGB and OAGB supports the concept of metabolic competence of duodeno-jejunal exclusion. Altered bile flow after duodeno-jejunal exclusion may be responsible for enhanced glucose metabolism improvement.

Bariatric emergencies: current evidence and strategies of management

BACKGROUND

The demand for bariatric surgery is increasing and the postoperative complications are seen more frequently. The aim of this paper is to review the current outcomes of bariatric surgery emergencies and to formulate a pathway of safe management.

METHODS

The PubMed and Google search for English literatures relevant to emergencies of bariatric surgery was made, 6358 articles were found and 90 papers were selected based on relevance, power of the study, recent papers and laparoscopic workload. The pooled data was collected from these articles that were addressing the complications and emergency treatment of bariatric patients. 830,998 patients were included in this review.

RESULTS

Bariatric emergencies were increasingly seen in the Accident and Emergency departments, the serious outcomes were reported following complex operations like gastric bypass but also after gastric band and the causes were technical errors, suboptimal evaluation, failure of effective communication with bariatric teams who performed the initial operation, patients factors, and delay in the presentation. The mortality ranged from 0.14%-2.2% and increased for revisional surgery to 6.5% (p = 0.002). Inspite of this, mortality following bariatric surgery is still less than that of control group of obese patients (p = value 0.01).

CONCLUSIONS

Most mortality and catastrophic outcomes following bariatric surgery are preventable. The awareness of bariatric emergencies and its effective management are the gold standards for best outcomes. An algorithm is suggested and needs further evaluation.

Type 2 diabetes after gastric bypass: remission in five models using HbA1c, fasting blood glucose, and medication status

BACKGROUND

The remission rates of type 2 diabetes mellitus (T2DM) after Roux-en-Y gastric bypass (RYGB) vary according to the glycosylated hemoglobin A1c (HbA1c), fasting blood glucose (FG), and medication status. Our objectives were to describe remission using the American Diabetes Association standards for defining normoglycemia and to identify the factors related to the preoperative severity of T2DM that predict remission to normoglycemia, independent of weight loss, after RYGB. The setting was an urban not-for-profit community hospital.

METHODS

We performed a retrospective analysis of prospectively collected data from a cohort of 2275 patients who qualified for bariatric surgery (2001-2008). Five different models for defining remission (no diabetes medication and a FG <100 mg/dL; no diabetes medication and HbA1c <6.0; no diabetes medication and HbA1c <5.7%; no diabetes medication, FG <100 mg/dL, and HbA1c <6.0%; and no diabetes medication, FG <100 mg/dL, and HbA1c <5.7%) were compared in 505 obese patients with T2DM 14 months after RYGB. The secondary aims were to determine the effects of preoperative insulin therapy and the duration of known T2DM on remission.

RESULTS

Of the 505 patients, 43.2% achieved remission using the most stringent criteria (no diabetes medication, HbA1c <5.7%, and FG <100 mg/dL) compared with 59.4% using the most liberal definition (no diabetes medication and FG <100 mg/dL; P < .001). The remission rates were greater for patients not taking insulin preoperatively (53.8% versus 13.5%, P < .001) and for patients with a more recent preoperative T2DM diagnosis (8.9 versus 3.7 yr, P < .001).

CONCLUSION

Remission, defined at a threshold less than what would be expected to result in microvascular damage, was achieved in 43.2% of diabetic patients by 14 months after RYGB. A more recent diagnosis of T2DM and the absence of preoperative insulin therapy were significant predictors, regardless of how remission was defined, independent of the percentage of excess weight loss.

Intragastric Balloon (BIB system) in the treatment of obesity and preparation of patients for surgery - own experience and literature review

Despite the recognition of bariatric surgery as the only effective method of weight reduction, we remain in search of minimally invasive methods, both for the treatment of obesity and preparation of patients for surgical procedures. The aim of the study was to determine intragastric balloon (Allergan) implantation results as the only method of treating obesity, and patient preparation for further stages of abdominal hernia operations, as well as other surgical procedures.

MATERIAL AND METHODS

The study presented own results considering the use of Bioenteric Intragastric Balloons (BIB system) in the treatment of pathological obesity, and preparation of patients for bariatric surgery and abdominal hernia operations. The study group comprised 18 female and 7 male patients. Average patient age amounted to 50.6 and 54 years, respectively. Indications for intragastric balloon insertion were as follows: preparation for hernia (10 cases) and bariatric (5 patients) operations, and weight reduction management (8 patients). In two cases the implantation of the intragastric balloon served the preparation for gynecological and orthopedic (vertebral column) operations. One female patient was prepared for both bariatric and hernial surgery. The procedure was performed under general anesthesia. Statistical analysis considered 22 patients (one female patient was excluded from analysis, due to death, two other were excluded because of lack of sufficient data).Results. In case of two patients the intragastric balloon system was removed before 6 months had elapsed because of intolerance. One female patient died during the observation period for reasons not related to the procedure. The obtained BMI reduction ranged between 2 and 6 kg/m2, which amounted to a maximum weight loss of 24 kg. In one patient a weight gain of 2 kg was observed. Considering patients prepared for abdominal hernia operations weight reduction was greater and better maintained after the removal of the BIB system.

CONCLUSIONS

According to the authors of the presented study the intragastric balloon serves its role as a bridge to bariatric procedures and weight reduction, before planned extensive postoperative hernia operations. The use of the intragastric balloon only to reduce weight has no medical and economic justification.

Resolution of diabetes mellitus by ileal transposition compared with biliopancreatic diversion in a nonobese animal model of type 2 diabetes

BACKGROUND

It has been demonstrated that biliopancreatic diversion (BPD) and ileal transposition (IT) effectively induce weight loss and long-term control of type 2 diabetes in morbidly obese individuals. It is unknown whether the control of diabetes is better after IT or after BPD. The objective of this study was to investigate the effects of IT and BPD on the control of diabetes in an animal model.

METHODS

We performed IT and BPD on 10- to 12-week-old Goto-Kakizaki rats with a spontaneous nonobese model of type 2 diabetes, and we performed a series of detection. The rats were observed for 24 weeks after surgery.

RESULTS

Animals who underwent IT and BPD demonstrated improved glucose tolerance, insulin sensitivity and the secretion of glucagon-like peptide-1 compared with the sham-operated animals. Furthermore, IT resulted in a shorter duration of surgery and better postoperative recovery than BPD.

CONCLUSION

This study provides strong evidence for the crucial role of the hindgut in the resolution of diabetes after duodenum-jejunum bypass or IT. We confirmed that IT was associated with better postoperative recovery than BPD and had a similar control of diabetes as BPD in nonobese animals with type 2 diabetes.

Gastric bypass surgery improves glucose metabolism possibly by decreasing ghrelin levels in Goto-Kakizaki rats

AIM: To investigate the influence of gastric bypass (GBP) surgery on glucose metabolism in Goto-Kakizaki (GK) rats and to explore the possible mechanisms involved.

METHODS: Twenty male GK rats and 10 male Wistar rats were randomized into three groups: GK operation group, GK sham operation group and Wistar sham operation group. The GK operation group underwent gastric bypass surgery. The levels of fasting plasma glucose (FPG), glycosylated hemoglobin (HbAlc), serum insulin (INS) and ghrelin were monitored 1 week before surgery and 1, 2, 4, 8 and 12 weeks after surgery.

RESULTS: In the GK operation group, FPG level decreased from (11.36 ± 1.14) mmol/L before surgery to (8.36 ± 0.62) mmol/L 12 weeks after surgery, and HbAlc from (8.91 ± 0.36)% to (6.35 ± 0.46)%. Serum INS increased from (32.70 ± 2.37) mIU/L before surgery to (55.14 ± 5.45) mIU/L 12 weeks after surgery, while serum ghrelin level decreased from (928.53 ± 58.66) pg/mL to (367.83 ± 27.78) pg/mL. All the above parameters differed significantly between before surgery and 12 weeks after surgery (all P < 0.05).

CONCLUSION: GBP can significantly improve glycometabolism in GK rats possibly by decreasing ghrelin levels and promoting insulin secretion.

Surgical treatment of morbid obesity and type 2 diabetes mellitus: current situation and future prospects

Along with social progress and life style transformation, morbid obesity, type 2 diabetes mellitus, and metabolic syndrome are increasingly becoming a great threat to human health. Because conventional conservative treatment has little effect on these diseases, they were considered incurable before. However, surgery shows good results in the treatment of these diseases and has therefore revolutionized their treatment. This review aims to elucidate the therapeutic mechanisms of surgery for morbid obesity and 2 diabetes mellitus and to discuss the current situation and future prospects of surgical treatment of these diseases.

Gastric bypass and glucose metabolism

Roux-en-Y gastric bypass leads to a marked improvement of glucose control. The mechanisms are only partly known. Gastrointestinal hormones may play a role. Of these, glucagon-like peptide 1 and peptide YY have been most consistently associated with the beneficial effects of gastric bypass on glucose metabolism and weight. In this paper, a short review of the topic is presented and a suggestion of the improvement of glucose metabolism is made based on the current published work.

Sleeve gastrectomy provides a better control of diabetes by decreasing ghrelin in the diabetic Goto-Kakizaki rats

AIM

Sleeve gastrectomy (SG) and modified duodenal jejunal bypass (MDJB) were compared as procedures for glucose control. We aim to form the initial conclusions with respect to the possibility of (1) whether gastric fundus exclusion is essential for the control of diabetes and (2) application as a low morbidity procedure.

MATERIALS AND METHODS

SG and MDJB were performed on 10- to 12-week-old Goto-Kakizaki rats that spontaneously develop type 2 diabetes. Rats were observed for 36 weeks after surgery, and glucose, insulin, glucagons-like peptide-1 (GLP-1), glucose tolerate, insulin sensitivity, cholesterol, triglycerides, and free fatty acid levels were measured.

RESULTS

Apart from distinct weight loss of SG and MDJB after 1 month compared with sham-operated rats (P < 0.001), SG showed strikingly improved blood glucose levels and significantly decreased Ghrelin secretion (P < 0.001). Furthermore, SG resulted in a shorter operative time (P < 0.01) and postoperative recovery time (P < 0.01) than MDJB group.

CONCLUSIONS

SG shows better control in terms of glucose tolerance and other measurements. This study provides direct evidence that SG possesses better improvement of diabetes by reduction of Ghrelin.

Feasibility of a supervised inpatient low-calorie diet program for massive weight loss prior to RYGB in superobese patients

BACKGROUND

This study was undertaken to determine the feasibility of an inpatient low-calorie program for a substantial decrease of preoperative weight (>10 points in BMI) in superobese patients.

METHODS

Five patients were hospitalized for an average of 11 weeks and were placed on a low-calorie liquid diet (<900 kcal/day) and an exercise program. Following a drop of ten points in BMI, they underwent a Roux-en-Y gastric bypass (RYGB). Hemoglobin A1c and lipid profiles were obtained at the beginning of the diet, prior to surgery and at the last follow-up appointment. Our results were compared to the National Surgical Quality Improvement Program (NSQIP) database, which included 1,046 bariatric operations performed at VA centers between October 1999 and August 2007.

RESULTS

All five patients were massively obese men (body mass index (BMI) = 64.3 +/- 2.1 kg/m(2); 54.7 +/- 2.6 years old; four of five were white) with multiple comorbid conditions, which placed them in a substantially higher risk for bariatric surgery. Of the four diabetic patients, two were insulin dependent. There was an average decrease in BMI by 12.7 points (85.8 +/- 6.0 lb) during the preoperative diet period (11 weeks). All patients underwent RYGB without complications. This cohort of patients further decreased their BMI by 10.6 points (88.4 +/- 29.4 lb) following surgical intervention. The total combined preoperative and postoperative excess body weight loss was 89% (10.6-month average follow-up). Sleep apnea resolved following gastric bypass but did not improve during the preoperative weight loss period. Hypertension, osteoarthritis, and dyslipidemia all improved following surgical intervention. Hemoglobin A1c decreased by 1.9% during diet-induced weight loss with no further improvement being noted after surgery. The two insulin-dependent diabetic patients discontinued insulin therapy following surgery. The NSQIP database contained 77 patients with similar characteristics to our cohort of patients. The 30-day mortality for this cohort of patients was 3.9% with a complication rate of 33.8%.

CONCLUSIONS

Massive preoperative weight loss is possible to achieve with a liquid protein diet in superobese patients greatly facilitating gastric bypass surgery in an otherwise high-risk patient population.

Adiposopathy and bariatric surgery: is 'sick fat' a surgical disease?

OBJECTIVE

To review how bariatric surgery in obese patients may effectively treat adiposopathy (pathogenic adipose tissue or 'sick fat'), and to provide clinicians a rationale as to why bariatric surgery is a potential treatment option for overweight patients with type 2 diabetes, hypertension, and dyslipidaemia.

METHODS

A group of clinicians, researchers, and surgeons, all with a background in treating obesity and the adverse metabolic consequences of excessive body fat, reviewed the medical literature regarding the improvement in metabolic disease with bariatric surgery.

RESULTS

Bariatric surgery improves metabolic disease through multiple, likely interrelated mechanisms including: (i) initial acute fasting and diminished caloric intake inherent with many gastrointestinal surgical procedures; (ii) favourable alterations in gastrointestinal endocrine and immune responses, especially with bariatric surgeries that reroute nutrient gastrointestinal delivery such as gastric bypass procedures; and (iii) a decrease in adipose tissue mass. Regarding adipose tissue mass, during positive caloric balance, impaired adipogenesis (resulting in limitations in adipocyte number or size) and visceral adiposity are anatomic manifestations of pathogenic adipose tissue (adiposopathy). This may cause adverse adipose tissue endocrine and immune responses that lead to metabolic disease. A decrease in adipocyte size and decrease in visceral adiposity, as often occurs with bariatric surgery, may effectively improve adiposopathy, and thus effectively treat metabolic disease. It is the relationship between bariatric surgery and its effects upon pathogenic adipose tissue that is the focus of this discussion.

CONCLUSIONS

In selective obese patients with metabolic disease who are refractory to medical management, adiposopathy is a surgical disease.

Apolipoprotein A-IV, a putative satiety/antiatherogenic factor, rises after gastric bypass

Roux-en-Y gastric bypass surgery (RYGBP) leads to improvements in satiety and obesity-related comorbidities. The mechanism(s) underlying these improvements are not known but may be revealed in part by discovery proteomics. Therefore, fasting plasma was collected from 12 subjects (mean BMI >45) during RYGBP and during a second procedure approximately 17 months later. Body weight, obesity-related comorbidities, and medication use were decreased after RYGBP. Mass spectrometry-based proteomic analysis was performed on a subset of seven samples using isobaric isotope-coded affinity tags (four plex iTRAQ). Initial proteomic analysis (n = 7) quantified and identified hundreds of plasma proteins. Manual inspection of the data revealed a 2.6 +/- 0.5-fold increase in apolipoprotein A-IV (apo A-IV, gene designation: APOA4), a approximately 46-kDa glycoprotein synthesized mainly in the bypassed small bowel and liver after RYGBP. The change in apo A-IV was significantly greater than other apolipoproteins. Immunoblot analysis of the full longitudinal sample set (n = 12) indicated even higher increases (8.3 +/- 0.2 fold) in apo A-IV. Thus iTRAQ may underestimate the changes in protein concentrations compared to western blotting of apo A-IV. Apo A-IV inhibits gastric emptying and serves as a satiety factor whose synthesis and secretion are increased by the ingestion of dietary fat. It also possesses anti-inflammatory and antiatherogenic properties. Based on these functions, we speculate changes in apo A-IV may contribute to weight loss as well as the improvements in inflammation and cardiovascular disease after RYGBP. In addition, the findings provide evidence validating the use of iTRAQ proteomics in discovery-based studies of post-RYGBP improvements in obesity-related medical comorbidities.

The Practice of Pancreatic Resection after Roux-en-Y Gastric Bypass

The morbid obesity epidemic in the United States has resulted in increasing numbers of patients who have undergone Roux-en-Y gastric bypass who require surgical management of nonbariatric disorders. When pancreatic resection is indicated in bariatric patients, consideration of the altered foregut anatomy can be applied to the principles of pancreatic resection to foster effective techniques that minimize operative complications. A retrospective review and analysis of bariatric patients who underwent pancreatic resection at the Medical University of South Carolina Digestive Center over a 2-year period (2006 to 2007) was conducted to assess indications for operation, operative techniques, and postoperative outcome in patients with previous Roux-en-Y gastric bypass. There were five patients (four female, one male) identified with a mean age of 35 years (range, 32–50 years). The mean time interval from gastric bypass to pancreatic resection was 42.6 months (range, 10–72 months). Indications for pancreatic operations were islet hyperplasia in two patients, chronic pancreatitis in two, and serous cystadenoma in one. Two patients underwent duodenal-preserving pancreatic head resection (Beger procedure) and three underwent distal pancreatectomy and splenectomy. Mean length of hospital stay was 11.4 days (range, 5–22 days). Two patients had extended hospital stay as a result of gastrointestinal ileus. There was no other operative morbidity or mortality. Mean length of patient follow up was 9.8 months (range, 1–17 months). Specific operative techniques used in pancreatic head resection were duodenal preservation, pancreatic drainage with an omega loop constructed from a mid-Roux limb, and excluded stomach gastrostomy. Techniques used in pancreatic tail and body resection were splenectomy discontinuous from pancreatectomy, division of the splenic vein and artery at the pancreatic neck early in surgery, retrograde dissection of the pancreas body and tail, and dissection of the body and tail posterior to the Roux limb leaving the Roux limb intact. Pancreatic resection after Roux-en-Y gastric bypass is safe and effective when using prescribed operative principles that minimize disruption of the foregut reconstruction and adds protection to the gastric remnant with a gastrostomy for decompression and access for enteral alimentation when necessary.

Ileal transposition controls diabetes as well as modified duodenal jejunal bypass with better lipid lowering in a nonobese rat model of type II diabetes by increasing GLP-1

OBJECTIVE

Modified duodenal jejunal bypass (MDJB) and ileal transposition (IT) were compared as surgeries for glucose control. Initial conclusions might be formed with respect to the possibility of (1) whether duodenal exclusion is essential for the control of diabetes and (2) application as a low morbid procedure.

SUMMARY BACKGROUND DATA

IT, MDJB, sham-IT, and sham-MDJB procedures were performed on 10- to 12-week-old Goto-Kakizaki (GK) rats, nonobese animals who spontaneously develop type 2 diabetes. Rats were observed for 24 weeks after surgery. Glucose, insulin, glucagon-like peptide-1 (GLP-1), glucose tolerance, insulin sensitivity, cholesterol, triglycerides, and free fatty acid levels were measured.

RESULTS

MDJB and IT rats, when compared with sham-operated rats, showed reduced blood-glucose levels (P < 0.001); but IT- and MDJB did not differ from one another (P < 0.05). Compared with sham-operated rats, IT- and MDJB rats showed increased GLP-1 secretion (P < 0.01), with a more rapid and higher secretion in IT operated than in MDJB rats (P < 0.05). After 6 months, sham-operated rats weighed more than IT or MDJB rats (P < 0.01), but the weights of IT- and MDJB rats were similar to one another (P > 0.05). In terms of both operative time (P < 0.001) and postoperative recovery time (P < 0.001), MDJB took longer than did IT.

CONCLUSION

In nonobese spontaneously diabetic rats, IT is equivalent to MDJB in terms of glucose control and weight secondary to significant increases of GLP-1. IT is faster to perform and yields a shorter recovery period than does MDJB.

Gastrointestinal surgery as treatment for type 2 diabetes

PURPOSE OF REVIEW

As the incidence of type 2 diabetes continues to rise worldwide at epidemic proportions, endeavors to find more effective therapies increase. Gastrointestinal bypass surgery is now gaining awareness as a potential effective and long-term treatment.

RECENT FINDINGS

There is now a substantial body of evidence supporting the efficacy of gastrointestinal surgery in controlling type 2 diabetes. This is well documented in several studies of obese diabetic patients undergoing gastrointestinal bypass procedures. Additionally, smaller studies and case reports also demonstrate the efficacy of gastrointestinal bypass surgery in nonobese diabetic patients. The pathophysiologic basis of the improvement in diabetes after gastrointestinal bypass surgery is still unclear; however, the dominant hypotheses involve changes in hormone signaling from the small bowel.

SUMMARY

The implications of 'diabetes surgery' are vast, and could dramatically change the face of diabetes as we know it today. In clinical practice surgery could represent an alternative for the treatment of diabetes. On a broader perspective, surgery may facilitate research aimed at understanding the etiology of the disease.

Preserving insulin secretion in Type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is a complex disease characterized by insulin resistance and a progressive decline in β-cell function and mass. Current evidence suggests that β-cell dysfunction is present early in the course of the disease and that this dysfunction, rather than insulin resistance, is primarily responsible for the progression of T2DM. β-cell dysfunction can be accelerated by glucose toxicity, lipotoxicity, oxidative stress, chronic increases in inflammatory mediators and, potentially, the use of sulfonylureas. This review suggests that future efforts to limit the impact of T2DM must focus on strategies to preserve β-cell function. Several interventions have shown promise in this regard, including lifestyle modifications, thiazolidinediones, potassium channel openers, incretin mimetics, cytokine antagonists, bariatric surgery and dipeptidyl peptidase IV inhibitors, although therapeutic insulin remains the most robust and physiological approach.