Potential of Surgery for Curing Type 2 Diabetes Mellitus

Francesco Rubino, MD, Michel Gagner, MD, FACS, FRCSC

Disclosures

Annals of Surgery. 2002;236(5) 

In This Article

Abstract and Introduction

Objective: To review the effect of morbid obesity surgery on type 2 diabetes mellitus, and to analyze data that might explain the mechanisms of action of these surgeries and that could answer the question of whether surgery for morbid obesity can represent a cure for type 2 diabetes in nonobese patients as well.
Summary Background Data: Diabetes mellitus type 2 affects more than 150 million people worldwide. Although the incidence of complications of type 2 diabetes can be reduced with tight control of hyperglycemia, current therapies do not achieve a cure. Some operations for morbid obesity not only induce significant and lasting weight loss but also lead to improvements in or resolution of comorbid disease states, especially type 2 diabetes.
Methods: The authors reviewed data from the literature to address what is known about the effect of surgery for obesity on glucose metabolism and the endocrine changes that follow this surgery.
Results: Series with long-term follow-up show that gastric bypass and biliopancreatic diversion achieve durable normal levels of plasma glucose, plasma insulin, and glycosylated hemoglobin in 80% to 100% of severely obese diabetic patients, usually within days after surgery. Available data show a significant change in the pattern of secretion of gastrointestinal hormones. Case reports have also documented remission of type 2 diabetes in nonmorbidly obese individuals undergoing biliopancreatic diversion for other indications.
Conclusions: Gastric bypass and biliopancreatic diversion seem to achieve control of diabetes as a primary and independent effect, not secondary to the treatment of overweight. Although controlled trials are needed to verify the effectiveness on nonobese individuals, gastric bypass surgery has the potential to change the current concepts of the pathophysiology of type 2 diabetes and, possibly, the management of this disease.

Morbid obesity, in which patients exceed their ideal weight by at least 100 lb or are more than 200% of ideal body weight, is a condition with high mortality and morbidity because of its association with severe comorbid diseases such as hypertension, diabetes, hyperlipidemia, and cardiopulmonary failure. In these patients, surgery represents the most effective therapy in that it achieves significant and durable weight loss as well as resolution or amelioration of comorbidities.[4] Current indications for surgery in morbidly obese patients include body mass index (BMI) greater than 40 or greater than 35 if comorbidities are present.[5]

Several operative procedures are performed for treatment of morbid obesity. Roux-en-Y gastric bypass (GBP) is usually done by dividing the stomach with a stapler to create a small gastric pouch, while the jejunum is divided 30 to 50 cm distal to the ligament of Treitz. The distal limb of the jejunum is then anastomosed to the small gastric pouch and a jejunojejunostomy is performed 50 to 150 cm distal from the gastrojejunostomy. Most studies report a weight loss of 60% to 70% of excess body weight.[7] In recent series, operative mortality ranges between 0% and 1.5%,[8,9,10] and the overall incidence of major complications, including anastomotic leaks, pulmonary embolus, and bowel occlusions, is between 0.6%[11] and 6%.[12]

Biliopancreatic diversion (BPD), introduced by Scopinaro in 1978, includes a gastric resection and diversion of the biliopancreatic juice to the terminal ileum to significantly reduce the absorption of nutrients.[13] In this operation, an enteroentero-anastomosis is performed between the proximal limb of the transected jejunum and ileum, 50 to 100 cm[14] proximally to the ileocecal valve. In a series of 2,241 patients reported by Scopinaro et al, the BPD resulted in a mean permanent reduction of about 75% of the initial excess weight, with an operative mortality of 0.5%.[15]

Gastroplasties, which include gastric banding and vertical banded gastroplasty, reduce the volume of the stomach by annular banding or vertical stapling but without bypassing the proximal foregut. Up to 65% of excess weight loss at 5 years has been reported,[16] but there is considerable variation in results among different authors, and a significant number of patients require reoperation for inadequate weight loss.[17]

Bariatric surgery is now increasingly being performed laparoscopically, resulting in a similar percentage of weight loss with respect to the open series[18,19] and reduced recovery time and perioperative complications.[20]

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