GI Surgery, specially Roux-en-Y gastric bypass (RYGB), is currently the most accepted surgical procedure to treat T2DM, and has also demonstrated to reduce significantly other cardiovascular risk factors (lipids and blood pressure control) when compared with optimal medical treatment, with good long-term effects on cardiovascular risks and mortality.
Full Answer
How does Metabolic Surgery help people with diabetes?
In individuals with severe obesity, surgery can: In addition to controlling diabetes and assisting weight loss, metabolic surgery can help patients: Many patients turn to metabolic surgery — also known as diabetes surgery — when medication, a healthier diet, and lifestyle changes fail to keep their diabetes under control.
Is there a surgery for type 2 diabetes?
Metabolic Surgery: Surgical Treatment for Type 2 Diabetes. Metabolic surgery includes surgery for diabetes (indeed the term “diabetes surgery” is gaining recognition), surgery for obesity and metabolic syndrome, and also surgery for weight reduction when weight per se represents a significant burden on quality of life.
Is glycemia secondary to weight loss after gastrointestinal surgery?
Consequently, weight loss and T2DM control might be considered two separate outcomes of gastrointestinal surgery, which means that improvement of glycemia is not necessarily secondary to weight loss. Possible neuroendocrine mechanisms
What are the benefits of gastric bypass surgery for non-insulin-dependent diabetes mellitus?
The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg. 1997;1:213–20. [PubMed] [Google Scholar] 24. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;199:543–51. [PubMed] [Google Scholar] 25.
How to improve T2DM after gastrointestinal surgery?
What is the role of the gastrointestinal tract in the metabolism of food?
What are the different types of bariatric surgery?
What is a bariatric banding operation?
How long does it take for a T2DM to stabilize?
What is gastrointestinal bypass?
Does surgical manipulation of the gastrointestinal tract affect T2DM?
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About this website
What is metabolic surgery for diabetes?
Bariatric surgery that aims to treat the comorbid conditions, such as diabetes mellitus associated with obesity, is generally called as metabolic surgery. In addition to the above-mentioned most widely used bariatric procedures, various metabolic surgical procedures have been developed to treat T2DM.
Which surgery is used as type 2 diabetes treatment?
Bariatric (Weight-Loss) Surgery for Treating Diabetes. Weight-loss surgery, also called bariatric surgery, can be done in minimally invasive ways and can be used to treat Type 2 diabetes. The surgery treats diabetes by controlling how much sugar is in the blood. One type of surgery is called the duodenal switch.
Which bariatric surgery is best for type 2 diabetes?
Bariatric surgery—either gastric bypass or sleeve gastrectomy—is recommended for people with type 2 diabetes and a body mass index of 40 or above.
What is metabolic syndrome surgery?
Metabolic bariatric surgery can dramatically improve or cure diabetes in some obese patients including a group that does not strictly meet the criteria of morbid obesity. Metabolic surgery can normalize blood glucose levels and allow for a discontinuation of insulin therapy.
What is the best surgery for diabetes?
Biliopancreatic diversion with a duodenal switch The doctor removes a large part of the stomach and also changes the way food moves to the intestines. Pros: It's the most effective surgery for people with diabetes.
How does bariatric surgery help type 2 diabetes?
Bariatric surgery can improve type 2 diabetes by lowering blood sugar and reducing the need for medications. It may even result in long-term or permanent remission from diabetes. However, bariatric surgery is considered a major surgery, and it does carry some short- and long-term risks and side effects.
What is the difference between metabolic and bariatric surgery?
Bariatric surgery is for all patients with a very high weight who need weight loss surgery. Metabolic surgery is used with the specific intent to address diabetes and metabolic dysfunctions that have failed to respond to lifestyle and medication changes as opposed to obesity per se.
Will bariatric surgery prevent type 2 diabetes?
Bariatric/metabolic surgery helps to cure and prevent type 2 diabetes, improve overall glycemic control, increase remission of type 2 diabetes, and reduce overall mortality in diabetic patients. Bariatric surgery is currently considered the most effective therapy for morbid obesity with uncontrolled diabetes.
What are the risks of bariatric surgery?
As with any major procedure, bariatric surgery poses potential health risks, both in the short term and long term....They can include:Bowel obstruction.Dumping syndrome, which leads to diarrhea, flushing, lightheadedness, nausea or vomiting.Gallstones.Hernias.Low blood sugar (hypoglycemia)Malnutrition.Ulcers.Vomiting.More items...•
What are the five signs of metabolic syndrome?
Here are the five signs or risk factors that could lead to metabolic syndrome.Elevated Blood Sugar Levels. ... Increased Blood Pressure. ... High Triglyceride Level. ... Reduced HDL Level. ... A Large Waist. ... Maintain Healthy Eating Habits. ... Stay Active. ... Limit Saturated Fat and Salt in Your Diet.More items...•
What is an example of a metabolic disease?
Metabolic syndrome is a cluster of conditions that occur together, increasing your risk of heart disease, stroke and type 2 diabetes. These conditions include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.
What is metabolic syndrome and how is it treated?
Metabolic syndrome is a group of risk factors that include abdominal fat, high blood pressure, high blood sugar, and unhealthy cholesterol levels. Treatment is focused on tackling each of these conditions. The goal is to cut your odds of blood vessel disease and heart disease, as well as diabetes.
How to improve T2DM after gastrointestinal surgery?
In a randomized, controlled trial, 80 patients with a BMI of 30–35 kg/m2were treated with either a strict medical regimen that included a very low calorie diet, lifestyle modification, and pharmacotherapy, or LAGB.4At baseline, 38% of patients in each group had been diagnosed with the metabolic syndrome; 2 years after surgery, metabolic syndrome was prevalent in 24% of nonsurgically treated patients but in only 3% of those treated with surgery. Another research group reported remarkable reduction of fasting plasma glucose levels in a prospective series of 37 patients with BMI <35 kg/m2who underwent laparoscopic RYGB.2
What is the role of the gastrointestinal tract in the metabolism of food?
The gastrointestinal tract is the first organ to receive information about the nutrient load of a meal and, as an endocrine organ, it transmits this information via hormonal secretion and direct neural signaling to peripheral tissues, as well as the brain, thereby modulating the control of metabolism. As a consequence, the gastrointestinal tract has a major role in the integration of nutrients with metabolic responses and changes in its anatomy can, predictably, have profound effects in the control of metabolism. In fact, the effects of surgical manipulation of the intestine on T2DM, independent of weight-loss, are consistent with the hypothesis that the gastrointestinal tract has a physiological role in glucose homeostasis and might also have a role in abnormalities of glucose homeostasis, such as insulin resistance and T2DM. Dysfunction of the gastrointestinal tract could provide a potential explanation for the link between excess nutrition and the development of insulin resistance and T2DM. The passage of excess nutrients in general or an increase in the passage of specific nutrients through the gastrointestinal tract could trigger intestinal neuroendocrine dysfunction, possibly owing to an overstimulation (see the discussion below on anti-incretin theory). Consistent with the role of excessive nutrient stimulation, all forms of restriction of nutrient passage throughout the intestine invariably result in improvement of T2DM, and the data suggest a positive correlation between the decrease of nutrient stimulation (‘intestinal rest’) and the degree of improvement of T2DM (that is, diet, restrictive surgery and gastric bypass surgery are associated with relatively small, medium and relatively great improvement, respectively) (Figure 3).
What are the different types of bariatric surgery?
Bariatric surgical procedures have traditionally been divided into three categories: restrictive, malabsorbitive, or mixed surgery. This classification is made on the assumption that bariatric surgery controls only food intake and/or nutrient absorption. According to this conventional view, restrictive surgical procedures, such as laparoscopic adjustable gastric banding (LAGB) or vertical banded gastroplasty (VBG), induce early satiety during meals by decreasing the volume of the stomach (Figures 1a and 1b). Malabsorbitive procedures (Figures 1c and 1d), such as bilio–pancreatic diversion (BPD), divert bile into the terminal segment of the ileum so that bile and food are only mixed in the final 50–100 cm of the small bowel, thereby drastically reducing nutrient absorption. Mixed procedures, such as Roux-en-Y gastric bypass (RYGB), involves restriction of the stomach and bypass of the small bowel, which is, however, shortened much less than it is in BPD (Figure 1e). Other novel procedures, such as duodenal–jejunal bypass (DJB), ileal interposition and sleeve gastrectomy are becoming increasingly popular owing to their ability to cause dramatic weight loss and/or substantial improvement of glycemic regulation among both obese and nonobese patients (Figure 2). Nevertheless, RYGB, LGB and BPD remain the most widely used treatments for morbid obesity.1
What is a bariatric banding operation?
Conventional bariatric operations. aDuring laparoscopic adjustable gastric banding, the upper part of the stomach is encircled by a saline-filled tube. The extent of restriction can be adjusted by injecting/withdrawing saline solution to/from the tube. bDuring Roux-en-Y gastric bypass, a surgical stapler is used to create a small, vertical gastric pouch. The upper pouch, which is completely separated from the gastric remnant, is anastomosed to the jejunum, whereas the excluded biliary limb is anastomosed to the alimentary limb. After surgery, ingested food bypasses about 95% of the stomach, the entire duodenum and a portion of the jejunum, but bile and nutrients mix in the distal jejunum and can be absorbed through the remaining portion of the small bowel. Biliopancreatic diversion involves a horizontal resection (c) or a vertical resection (d,also known as ‘sleeve gastrectomy’ or ‘duodenal switch’). The reduced stomach is anastomosed to the distal 250 cm of the small intestine. The excluded small intestine, which carries the bile and pancreatic secretions, is connected to the alimentary limb. Bile and nutrients mix in a short segment of small bowel, the only site where fat and starches are absorbed; noncaloric nutrients are absorbed in the alimentary limb.
How long does it take for a T2DM to stabilize?
After surgery, the patients’ HbA1Clevels normalized within 3 months, and stabilized after 9 months at 5–6% (from 8–9% preoperatively). Importantly, neither patient lost weight, which suggests that surgery evoked weight-independent antidiabetic mechanisms. In another study, marked reductions were observed in fasting glycemic levels and HbA1Clevels after laparoscopic DJB, and 18 out of 20 patients with BMI <30 kg/m2discontinued antidiabetic medications.17Another study found a decrease in antidiabetic medication requirements after DJB but only modest improvements of HbA1Clevels (from 9.4 to 8.5%) and blood glucose levels (from 11.60 mmol/l to 8.55 mmol/l).18Ileal interposition alone or in combination with SG among 60 patients with T2DM and BMI 24–34 kg/m2resulted in adequate glycemic control in 87% of patients at a mean follow-up of 7.4 months.19,20
What is gastrointestinal bypass?
Gastrointestinal bypass procedures connect two otherwise separated segments of the gastrointestinal tract, thereby allowing nutrients to reach the distal portion of the small intestine more rapidly than usual and bypassing the contact of nutrients with much of the stomach, the entire duodenum and part of the jejunum. Two major hypotheses exist for improvement of glycemia following gastrointestinal surgery. According to the ‘lower intestinal hypothesis’53(also known as ‘distal’ or ‘foregut’ hypothesis54), the rapid delivery of nutrients to the lower intestine increases stimulation of L-cells, which results in increased secretion of hormones that enhance insulin release and/or insulin action (for example, GLP-1), and a subsequent decrease in blood glucose levels. According to the ‘upper intestinal hypothesis’53(also defined as ‘proximal’ of ‘hindgut’ hypothesis54), gastrointestinal bypass reduces the secretion of upper gastrointestinal factors that decrease insulin secretion and/or promote insulin resistance. Reduction of the amount of these putative anti-insulin factors (or anti-incretins) would increase insulin action, and so improve symptoms of T2DM. Although the proximal and distal hypotheses are often conceptualized in terms of the release of hormones, they are also compatible with the theory that altered nutrient flow triggers neural signaling rather than hormone release.
Does surgical manipulation of the gastrointestinal tract affect T2DM?
Increasing evidence suggests that certain types of surgical manipulations of the gastrointestinal tract ameliorate T2DM by mechanism s other than weight loss and diminished caloric intake. A direct role of surgical manipulation of the gastrointestinal tract on diabetes mellitus was suggested by an experiment in nonobese diabetic rats (Goto-Kakizaki strain) that underwent DJB surgery.45These rats experienced substantially greater improvement of glucose homeostasis than matched control rats that had undergone sham operation, diet restriction or therapy with insulin-sensitizing drugs.45Similar findings have been reported in other studies that used in the same animal model46–48as well as in rodent models of diet-induced insulin resistance,49,50and numerous cases of glycemic improvement have been reported in humans following experimental gastrointestinal procedures that cause little to no weight loss.16,17Additional evidence of weight-independent mechanisms of T2DM control derives from observations that bypass surgical procedures induce higher rates of T2DMD remission than restrictive forms of bariatric surgery or nonsurgical interventions, despite equivalent weight loss, consistent with the study discussed above that compared the results of RYGB and dieting.44
Introduction
Several gastrointestinal (GI) operations, including partial gastrectomies ( 1, 2) and bariatric procedures ( Fig. 1) ( 3 – 5 ), promote dramatic, durable improvement of type 2 diabetes (T2D).
Executive Summary
T2D is associated with complex metabolic dysfunctions, leading to increased morbidity, mortality, and cost. Although population-based efforts through lifestyle interventions are essential to prevent obesity and diabetes, people who develop this disease should have access to all effective treatment options.
Methods
The DSS-II organizing committee and the partner diabetes organizations tasked a multidisciplinary group of 48 international authorities to develop a set of evidence-based recommendations.
Summary of Evidence: Clinical and Biological Rationale for Surgical Treatment of T2D
The GI tract is an important contributor to normal glucose homeostasis ( 35 ), and mounting evidence, especially over the past decade, has demonstrated benefits of bariatric/metabolic surgery to treat and prevent T2D ( 3, 5, 10 – 25, 51 – 53 ).
STATEMENTS AND RECOMMENDATIONS
Although obesity and T2D are often associated with one another, T2D is a disease entity with significant heterogeneity that presents distinct challenges for clinical care.
Article Information
Funding and Duality of Interest. The DSS-II and WCITD 2015 were supported by the International Diabetes Surgery Task Force (a nonprofit organization), King’s College London, King’s College Hospital, Johnson & Johnson, Medtronic, Novo Nordisk, Fractyl, DIAMOND MetaCure, Gore, MedImmune, and NGM Biopharmaceuticals.
How to improve T2DM after gastrointestinal surgery?
In a randomized, controlled trial, 80 patients with a BMI of 30–35 kg/m2were treated with either a strict medical regimen that included a very low calorie diet, lifestyle modification, and pharmacotherapy, or LAGB.4At baseline, 38% of patients in each group had been diagnosed with the metabolic syndrome; 2 years after surgery, metabolic syndrome was prevalent in 24% of nonsurgically treated patients but in only 3% of those treated with surgery. Another research group reported remarkable reduction of fasting plasma glucose levels in a prospective series of 37 patients with BMI <35 kg/m2who underwent laparoscopic RYGB.2
What is the role of the gastrointestinal tract in the metabolism of food?
The gastrointestinal tract is the first organ to receive information about the nutrient load of a meal and, as an endocrine organ, it transmits this information via hormonal secretion and direct neural signaling to peripheral tissues, as well as the brain, thereby modulating the control of metabolism. As a consequence, the gastrointestinal tract has a major role in the integration of nutrients with metabolic responses and changes in its anatomy can, predictably, have profound effects in the control of metabolism. In fact, the effects of surgical manipulation of the intestine on T2DM, independent of weight-loss, are consistent with the hypothesis that the gastrointestinal tract has a physiological role in glucose homeostasis and might also have a role in abnormalities of glucose homeostasis, such as insulin resistance and T2DM. Dysfunction of the gastrointestinal tract could provide a potential explanation for the link between excess nutrition and the development of insulin resistance and T2DM. The passage of excess nutrients in general or an increase in the passage of specific nutrients through the gastrointestinal tract could trigger intestinal neuroendocrine dysfunction, possibly owing to an overstimulation (see the discussion below on anti-incretin theory). Consistent with the role of excessive nutrient stimulation, all forms of restriction of nutrient passage throughout the intestine invariably result in improvement of T2DM, and the data suggest a positive correlation between the decrease of nutrient stimulation (‘intestinal rest’) and the degree of improvement of T2DM (that is, diet, restrictive surgery and gastric bypass surgery are associated with relatively small, medium and relatively great improvement, respectively) (Figure 3).
What are the different types of bariatric surgery?
Bariatric surgical procedures have traditionally been divided into three categories: restrictive, malabsorbitive, or mixed surgery. This classification is made on the assumption that bariatric surgery controls only food intake and/or nutrient absorption. According to this conventional view, restrictive surgical procedures, such as laparoscopic adjustable gastric banding (LAGB) or vertical banded gastroplasty (VBG), induce early satiety during meals by decreasing the volume of the stomach (Figures 1a and 1b). Malabsorbitive procedures (Figures 1c and 1d), such as bilio–pancreatic diversion (BPD), divert bile into the terminal segment of the ileum so that bile and food are only mixed in the final 50–100 cm of the small bowel, thereby drastically reducing nutrient absorption. Mixed procedures, such as Roux-en-Y gastric bypass (RYGB), involves restriction of the stomach and bypass of the small bowel, which is, however, shortened much less than it is in BPD (Figure 1e). Other novel procedures, such as duodenal–jejunal bypass (DJB), ileal interposition and sleeve gastrectomy are becoming increasingly popular owing to their ability to cause dramatic weight loss and/or substantial improvement of glycemic regulation among both obese and nonobese patients (Figure 2). Nevertheless, RYGB, LGB and BPD remain the most widely used treatments for morbid obesity.1
What is a bariatric banding operation?
Conventional bariatric operations. aDuring laparoscopic adjustable gastric banding, the upper part of the stomach is encircled by a saline-filled tube. The extent of restriction can be adjusted by injecting/withdrawing saline solution to/from the tube. bDuring Roux-en-Y gastric bypass, a surgical stapler is used to create a small, vertical gastric pouch. The upper pouch, which is completely separated from the gastric remnant, is anastomosed to the jejunum, whereas the excluded biliary limb is anastomosed to the alimentary limb. After surgery, ingested food bypasses about 95% of the stomach, the entire duodenum and a portion of the jejunum, but bile and nutrients mix in the distal jejunum and can be absorbed through the remaining portion of the small bowel. Biliopancreatic diversion involves a horizontal resection (c) or a vertical resection (d,also known as ‘sleeve gastrectomy’ or ‘duodenal switch’). The reduced stomach is anastomosed to the distal 250 cm of the small intestine. The excluded small intestine, which carries the bile and pancreatic secretions, is connected to the alimentary limb. Bile and nutrients mix in a short segment of small bowel, the only site where fat and starches are absorbed; noncaloric nutrients are absorbed in the alimentary limb.
How long does it take for a T2DM to stabilize?
After surgery, the patients’ HbA1Clevels normalized within 3 months, and stabilized after 9 months at 5–6% (from 8–9% preoperatively). Importantly, neither patient lost weight, which suggests that surgery evoked weight-independent antidiabetic mechanisms. In another study, marked reductions were observed in fasting glycemic levels and HbA1Clevels after laparoscopic DJB, and 18 out of 20 patients with BMI <30 kg/m2discontinued antidiabetic medications.17Another study found a decrease in antidiabetic medication requirements after DJB but only modest improvements of HbA1Clevels (from 9.4 to 8.5%) and blood glucose levels (from 11.60 mmol/l to 8.55 mmol/l).18Ileal interposition alone or in combination with SG among 60 patients with T2DM and BMI 24–34 kg/m2resulted in adequate glycemic control in 87% of patients at a mean follow-up of 7.4 months.19,20
What is gastrointestinal bypass?
Gastrointestinal bypass procedures connect two otherwise separated segments of the gastrointestinal tract, thereby allowing nutrients to reach the distal portion of the small intestine more rapidly than usual and bypassing the contact of nutrients with much of the stomach, the entire duodenum and part of the jejunum. Two major hypotheses exist for improvement of glycemia following gastrointestinal surgery. According to the ‘lower intestinal hypothesis’53(also known as ‘distal’ or ‘foregut’ hypothesis54), the rapid delivery of nutrients to the lower intestine increases stimulation of L-cells, which results in increased secretion of hormones that enhance insulin release and/or insulin action (for example, GLP-1), and a subsequent decrease in blood glucose levels. According to the ‘upper intestinal hypothesis’53(also defined as ‘proximal’ of ‘hindgut’ hypothesis54), gastrointestinal bypass reduces the secretion of upper gastrointestinal factors that decrease insulin secretion and/or promote insulin resistance. Reduction of the amount of these putative anti-insulin factors (or anti-incretins) would increase insulin action, and so improve symptoms of T2DM. Although the proximal and distal hypotheses are often conceptualized in terms of the release of hormones, they are also compatible with the theory that altered nutrient flow triggers neural signaling rather than hormone release.
Does surgical manipulation of the gastrointestinal tract affect T2DM?
Increasing evidence suggests that certain types of surgical manipulations of the gastrointestinal tract ameliorate T2DM by mechanism s other than weight loss and diminished caloric intake. A direct role of surgical manipulation of the gastrointestinal tract on diabetes mellitus was suggested by an experiment in nonobese diabetic rats (Goto-Kakizaki strain) that underwent DJB surgery.45These rats experienced substantially greater improvement of glucose homeostasis than matched control rats that had undergone sham operation, diet restriction or therapy with insulin-sensitizing drugs.45Similar findings have been reported in other studies that used in the same animal model46–48as well as in rodent models of diet-induced insulin resistance,49,50and numerous cases of glycemic improvement have been reported in humans following experimental gastrointestinal procedures that cause little to no weight loss.16,17Additional evidence of weight-independent mechanisms of T2DM control derives from observations that bypass surgical procedures induce higher rates of T2DMD remission than restrictive forms of bariatric surgery or nonsurgical interventions, despite equivalent weight loss, consistent with the study discussed above that compared the results of RYGB and dieting.44
