Bariatric Surgery in Type 2 Diabetes
Bariatric Surgery in Type 2 Diabetes
Obesity is a potent risk factor for the development and progression of type 2 diabetes, and weight loss is a key component of diabetes management. Bariatric surgery results in significant weight loss and remission of diabetes in most patients. After surgery, glycemic control is restored by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion.
Obesity is a potent risk factor for the development and progression of type 2 diabetes, and weight loss is a key component of diabetes management. Bariatric surgery results in significant weight loss and remission of diabetes on post patients. After surgery, glycemic control is restored by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion.
Obesity is one of the 10 leading US health indicators of increased risk of pulmonary diseases, cardiovascular diseases, diabetes, musculoskeletal diseases, and certain forms of cancers. The increasing prevalence of obesity in adult population triggered a concomitant rise in type 2 diabetes mellitus (T2DM). Obesity and insulin resistance are the main components of metabolic syndrome and result in impaired glucose metabolism. Those who suffer from both conditions are recently referred to as “diabesity patients”. Different obesity treatment strategies have been used, including prevention, lifestyle and dietary modification, behavioral therapy, and pharmacotherapy. A recent article published by Patti and Goldfine concluded that current therapies are not effective in providing a sustained weight loss. Of the various treatment options, bariatric surgery remains the most effective method to achieve a long-term weight loss. Post-surgical weight loss improves all obesity-related comorbidities with a good quality of life and decreased overall mortality rate. Also, post-bariatric surgical patients have demonstrated 83% reduction in diabetes incidence, 30–40% reduction in myocardial infarction and stroke, 42% reduction of cancer in women, and 30–40% reduction in overall mortality. There are several bariatric procedures currently available including laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), the biliopancreatic diversion with duodenal switch (LBPD-DS), and laparoscopic Roux-en-Y gastric bypass (LRYGB).
However, data on the effects of this surgery on type 2 diabetes come primarily from observational studies that lacked appropriate control groups, and the relative benefit of bariatric surgery vs. aggressive medical antidiabetic therapy is not yet known. Needed are randomized trials comparing the two types of therapy (and the various types of bariatric surgery) in diabetic patients with less-severe obesity.
Further, why would bariatric surgery help with diabetes, and why would one procedure do it better than another? Evidence points not only to weight loss but also to better insulin sensitivity and to alterations in levels of hormones secreted by the gut that increase insulin secretion.
What are the different types of procedures?
Laparoscopic adjustable gastric banding was the first bariatric technique to be performed by a laparoscopic approach. The operation is done by the creation of a small pouch in the upper part of the stomach with a controlled and adjustable stoma, without stapling, thus limiting food intake. The band is fitted around the fundus of the stomach, forming a 15–20 ml small pouch. The diabetes remission after LAGB can be achieved gradually and is associated with the degree of weight loss. Your doctor doesn’t have to cut the stomach or move the intestines, like in other surgeries. That’s one reason it has fewer complications. Also, you can get the band adjusted or taken out later. Forty-five percent to 60% percent of people who have this surgery end up diabetes-free. Sometimes there are problems with the band. It may slip or become worn, so you could need another surgery to fix it. Also, you’ll lose less weight with this surgery than others (about 40% to 50%).
Laparoscopic sleeve gastrectomy is a simple surgical technique with a low complication rate and minor long-term nutritional deficiencies. The operation is performed by resecting the greater curvature from the distal antrum (4 cm proximal to the pylorus) to the angle of His, including the complete fundus, by using a laparoscopic stapler. The remnant stomach tube was approximately 2 cm wide along the less curved side. The resected portion of the stomach was extracted from the extended periumbilical trocar site. A prospective study done by Silecchia et al. included 41 super-obese patients demonstrated that at 18th-month post SG, diabetes was cured in 76.9% and improved in 15.4% of patients.
LBPD-DS, in this operation, is a 60% distal gastric resection with the stapled closure of the duodenal stump results in a residual stomach volume of around 300 ml. The small bowel is transected 2.5 m from the ileocecal valve, and its distal end is anastomosed to the remaining stomach. The proximal end of the ileum, comprising the remaining small bowel carrying the biliopancreatic juice and excluded from food transit, is anastomosed to the bowel 50 cm proximal to the ileocecal valve. Consequently, the total length of absorbing bowel is 250 cm, the final 50 cm of which represents the site where ingested food and biliopancreatic juices mix.
Laparoscopic Roux-en-Y gastric bypass surgery - The surgeon makes a small stomach pouch by dividing the top of the stomach from the rest of it. When you eat, food goes to the small pouch and bypasses the top of the small intestine. The result: You get full faster and absorb fewer calories and nutrients.
Biliopancreatic diversion with a duodenal switch - This surgery is not common, partly because it’s the most complicated. The doctor removes a large part of the stomach and also changes the way food moves to the intestines.
Electric Implant Device - The surgeon implants an electrical device just beneath the skin of your abdomen. The device helps control signals in the vagus nerve which connects the stomach and the brain, reducing the feeling of hunger. Implanting the device is considered minor surgery and it can easily be removed once weight loss is achieved. The device can also be controlled remotely. Patients may experience pain, heartburn, problems swallowing, belching, nausea, and chest pain.
Several studies suggested that a decrease in plasma glucose level in T2DM patients after bariatric surgery is a result of a caloric restriction, not of a significant weight loss. Even though any decrease in caloric intake can improve plasma glucose levels and liver fat content, the mechanism of T2DM remission after bariatric surgery is still not fully elucidated. Numerous studies postulated that intestinal hormonal changes after bariatric surgery play an important role in T2DM remission and developed two hypotheses: the hindgut hypothesis and the foregut hypothesis.
Changes are also seen in adipocyte-derived hormones, leptin is correlated with insulin resistance whereas adiponectin enhances insulin sensitivity. After bypass surgery, a decrease in leptin level and a rise in adiponectin concentration are noted.
The best way to keep the weight off is to stick to your diet and exercise plan.
You’ll have to eat smaller meals. Choose a half-cup to a cup of vegetables and protein-rich foods per serving. Try lean cuts of meat, fish, beans, low-fat cheese, and yogurt.
It's a good idea to work with a nutritionist as you shift your eating habits, especially if your body doesn't absorb nutrients as well as it did before your surgery. Make sure you get enough of all the vitamins and minerals you need.
After you lose a lot of weight, you may want to consider plastic surgery to take up loose skin. That’s a separate procedure that you and your doctors can consider.
Obesity is a potent risk factor for the development and progression of type 2 diabetes, and weight loss is a key component of diabetes management. Bariatric surgery results in significant weight loss and remission of diabetes in most patients. After surgery, glycemic control is restored by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion.