Ed Ungar

April 16, 2008

April 16, 2008 (Philadelphia) — A new type of bariatric surgery may eliminate the need for medication in patients with type 2 diabetes, according to a study reported here at the Society of American Gastrointestinal and Endoscopic Surgeons 2008 Annual Scientific Session and Postgraduate Course.

It has long been observed that very obese patients — those with a body mass index (BMI) of 35 kg/m2 or more — with type 2 diabetes have noticeably better control over the disease after undergoing bariatric surgery. This makes sense because the more weight a patient gains, the worse his or her glycemic control becomes. Therefore, surgeries performed to assist in weight reduction should and do lead to improved diabetes management.

Just as not all obese people have type 2 diabetes, many nonobese people do have the disease, and it can be inferred that perhaps something else is triggering this condition. Researchers have posited that perhaps something in the stomach that promotes type 2 diabetes (a relatively new type 2 diabetes drug [Byetta, Amylin Pharmaceuticals Inc and Eli Lilly & Co) works on the basis of this principle).

The study reported here looked at surgical treatment of nonobese (BMI, 21 – 29 kg/m2) patients with type 2 diabetes. A total of 69 patients (22 women and 47 men) were enrolled who had a history of type 2 diabetes mellitus for at least 3 years and had evidence of stable treatment with oral hypoglycemic agents or insulin for at least 12 months.

The Brazilian surgeons who carried out the study used a relatively new procedure involving laparoscopic ileal interposition associated to a diverted sleeve gastrectomy. This surgery involves connecting the ileum to the proximal intestine, which keeps digestive nutrients away from the bowel early in the digestive process. Thus, mostly undigested nutrients hit that part of the bowel relatively early, and various hormones are therefore secreted earlier than they would be without the surgery.

The researchers conclude that the new surgery appears to be effective in controlling type 2 diabetes and its complications in nonobese patients. After surgery, 65% of patients achieved a hemoglobin A1C test score below 6 without the aid of insulin or oral medications. The patients' fasting glucose levels decreased from a mean of 218 to 102 mg/dL, postprandial glucose levels decreased from 305 to 141 mg/dL, and insulin resistance decreased from 5.2 to 0.77.

Measures of comorbidities of diabetes also showed improvement. Hypertension was controlled in 91.3% of the patients, microalbuminuria was resolved in 85%, cholesterol levels were normalized in 95%, and hypertriglyceridemia was normalized in 92% of the patients.

Average patient follow-up was 21.7 months, but lead investigator Aureo L. de Paula, MD, director of gastrointestinal surgery at Hospital de Especialidades, Goiania, Brazil, recommended longer follow-up. There were no deaths, but postoperative complications occurred in 7.3% of patients. There also were reports of short-term dehydration, and in the first 6 months there were cases of external contamination of the ileal segment, which can lead to gastroenteritis and diarrhea.

Dr. de Paula told Medscape General Surgery that the procedure is designed to deal with "the pathophysiology of the disease, such as the defective early phase in saline secretion and the defective amplification of the insulin response by the hormone GIP."

Francesco Rubino, MD, chief of gastrointestinal metabolic surgery at Weill Cornell Presbyterian Hospital, New York City, strongly agreed that hormonal and other action in the stomach profoundly affects type 2 diabetes. After all, he told Medscape General Surgery, for almost 100 years, there have been reports of diabetes improvement after stomach surgery for ulcers and cancer, which are in some ways similar procedures to modern gastric bypass surgery. However, Dr. Rubino said he has serious reservations concerning the new procedure.

Dr. Rubino said he is interested in laparoscopic Ileal interposition associated to a diverted sleeve gastrectomy and is currently performing the procedure on animals himself. However, he told Medscape General Surgery, that he is concerned about the long-term effects of the surgery, which are, at present, unknown. In addition, the surgery is much more complicated to perform than gastric bypass, which is already known to be a safe and effective procedure that accomplishes much the same thing as the new procedure.

"I do think [the procedure] is an intriguing operation. Whether it is ready for clinical prime time as a primary application — that I don't know," Dr. Rubino said.

Dr. de Paula is a consultant with Covidien. Dr. Rubino is a consultant for GI Dynamics and has received travel grants from Covidien.

Society of American Gastrointestinal and Endoscopic Surgeons 2008 Annual Scientific Session and Postgraduate Course: Abstract S085. Presented April 11, 2008.


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