Benefits of Bariatric Surgery for Type 2 Diabetes

For type 2 diabetes, mainly as a result of increased fat in the target organs for insulin resistance is caused by a chronic metabolic disease. The insulin resistance, blood sugar levels within the normal range at the start to maintain the pancreas to secrete more of the hormone causes. However, in the course of the disease, giving rise to a lack of insulin is not the exhaustion of the gland.bariatric-surgery-treats-diabetes

Bariatric surgery not only helps in weight loss but it also leads to remission of diabetes in the majority of people. Procedures that induce greater weight loss are associated with higher rates of diabetes remission.

The three main mechanisms of diabetes remission after bariatric surgery are

1. Weight loss ( predominantly loss of body fat)

2. Accelerated gastric emptying

3. Increased contact of undigested food with the distal small intestine

Weight loss – Body fat, predominantly the visceral adipose tissue, is a major risk factor for metabolic diseases and insulin resistance. This produces inflammatory cytokines which cause hyperglycemia, hyperglycemia and atherosclerosis leading to diabetes, hypertension, coronary artery disease and stroke. Due to loss of body weight and reduction of visceral fat, there is both a decrease in insulin demand within the body as well as a decrease in the peripheral insulin resistance. This is particularly helpful in those people with type 2 diabetes who basically have elevated insulin levels due to peripheral insulin resistance. The insulin levels have shown to be normalized after surgery with increased sensitivity of target tissues to insulin giving rise to normal blood sugar levels.

Accelerated gastric emptying- Most of restrictive procedures including sleeve gastrectomy and adjustable gastric banding cause the gastric emptying time to be shortened which leads to increased exposure of the small intestine to undigested food.

Gastric_Bypass_Illustration

Malabsortive procedures- The Malabsortive procedures cause undigested nutrients to come into direct contact with the small intestine. This causes rise in the levels of certain gut hormones known as incretions such as GLP-1. These hormones in turn stimulate insulin secretion from the pancreas. Increased insulin also up regulates the metabolism and causes more stored fat to be utilized for energy. As a consequence, weight loss is accelerated and it leads to diabetes remission.

Various studies and Meta analyses have shown normalization of fasting blood sugar/HbA1C levels in the majority of diabetic patients with long term improvement/remission of the disease. Comparative trials of bariatric surgery versus intensive medical treatment for remission of type 2 diabetes in obese people with BMI 30-40 kg/m2 (Dixon et al) have shown that surgical therapy was associated with significantly higher rate of diabetes remission (73% vs. 13%) and weight loss (20.1% vs 1.3%) as compared to medical treatment after 2 years Similar studies by Schauer and Migrone et al have shown significant remission of diabetes with decrease in medication after bariatric surgery

Diabetes Type 2
Diabetes Type 2

The rate of diabetes remission after bariatric surgery is determined by the type of procedure. It has been shown to be highest for Malabsortive procedures like BPD-DS and RYGB (> 50% remission in some studies) and is lesser for restrictive procedures like sleeve gastrectomy and gastric banding. The rate of diabetes remission is also determined by patient related factors. Those people with long standing diabetes, insulin use and poor blood sugar control pre operatively were found to have less rates of remission compared to other subjects

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Weight loss/ Bariatric surgery in delhi

Surgery for weight loss/ Bariatric surgeryweight loss

Surgery for weight loss /Bariatric surgery is a group of surgical procedures which help to decrease the body weight of an individual. It is indicated for people having morbid obesity (BMI> 35 kg/m2with significant comorbidities or BMI > 40 kg/m2 with or without associated comorbidities).  The reduction in body weight is primarily due to loss of body fat which is a result of the negative energy balance achieved after the surgery. This is done by either reducing the capacity of the stomach to limit the intake of food at one time (restrictive procedures) or by decreasing the effective length of intestine available for absorption of food (malabsorptive procedures) or both mechanisms (combined procedures).

Restrictive procedures include

  1. Gastric Sleeve in which the majority of stomach is removed using a stapling device to create a long, narrow tube of the stomach
  2. Gastric Banding in which an adjustable silicon band is placed around the upper portion of the stomach to limit the intake of food
  3. Gastric plication in which the stomach is sutured in 2 layers to reduce its capacity

Malabsorptive procedures include

  1. Jejunoileal Bypass in which the first part of the intestine is cut and connected directly to a part which is present distally reducing the effective length of the intestine. This procedure is not performed nowadays

Combined procedures

  1. Gastric Bypass – In this, a small pouch of stomach is created which is joined directly to the cut portion of the small intestine. The small pouch restricts the quantity of food taken while the intestine is bypassed to limit absorption.
  2. Biliopancreatic diversion- The stomach is divided as in a sleeve gastrectomy and the cut portion is connected to the small intestine for malabsorption

Bariatric surgery has been proven to be the only effective procedure for long term weight loss in patients with morbid obesity. Besides this, it helps in reversal or improvement of the majority of associated medical conditions and increases lifespan as well as the quality of life.

Gastric_Bypass_IllustrationA large number of scientific studies as well as meta-analyses have shown an average excess weight loss of more than 60% over a five year period. In absolute terms, this amounts to a weight loss of 35-50 kg depending upon the BMI of the individual and the procedure performed. Long term follow up (> 15 years) has shown that this weight is maintained in the majority of people.

Medical illnesses associated with morbid obesity like diabetes, hypertension, increased cholesterol and heart diseases have been shown to be improved or reversed in upto 60-80% of patients undergoing bariatric surgery. This leads to reduction in the cardiovascular morbidity and mortality. Other conditions like obstructive sleep apnea, joint disease, reflux disease and fatty liver have shown significant improvement after surgery in patients suffering from these conditions. The primary mechanism for this is weight loss and other factors such as decreased visceral fat and improvement in insulin resistance also contribute. Besides these, weight loss surgery is associated with improvement in gout, asthma, varicose veins, urinary incontinence and infertility.

Types of Bariatric Surgery

types-bariatric-surgeryBariatric surgery operations are classified by the mechanism by which they help to lose weight. They can either decrease the capacity of stomach and hence restrict food intake (restrictive procedures) or reduce the effective length of the intestine to decrease the absorption of food (malabsorptive procedures) or work by both mechanisms (combined procedures).

Restrictive procedures include

  1. Sleeve gastrectomy– The operation removes around 80% of the stomach using a specialized laparoscopic stapling gun. This staples the stomach on both sides and cuts in between which makes the procedure fast and bloodless. The volume of the stomach is reduced from initial 2000 cc to only 150 -200 cc. This markedly reduces the amount of food that can be consumed at one sitting.

Also, removal of the stomach reduces the level of hunger hormone (ghrelin). This makes the person satiated early and helps in weight loss. The 5 year expected excess weight loss for this procedure is up to 70%.

 

  1. Adjustable Gastric banding– In this procedure, an adjustable silicon band is placed around the upper end of the stomach which helps to regulate food intake and provide a sense of satiety to the patient. There is no cutting of stomach or bypass of the intestine which makes it one of the fastest and safest bariatric procedures to perform. The amount of fluid which is present within the band can adjusted from an access port placed under the skin which can tighten or loosen the band and regulate weight loss.

 

  1. Gastric plication– This is a novel bariatric procedure wherein a part of the stomach is sewn with non-absorbable sutures to reduce its size. The shape and volume of the stomach becomes similar to that seen after sleeve gastrectomy. However, this is an economical option for patients who cannot afford the previously mentioned procedures since stapling guns and cartridges which increase the cost of a procedure are not used in this procedure

 

Combined procedures include

 

  1. Roux en Y gastric bypass-. It is regarded as the gold standard bariatric procedure and was the most commonly performed bariatric surgery until recently sleeve gastrectomy took this place. In this procedure, the upper part of the stomach is converted into a small pouch to restrict intake andis connected directly to the mid part of the small intestine. This new anatomy bypasses the lower part of stomach and the first part of the small intestine which delays the mixing of food with the digestive enzymes and hence results in malabsorption.

The combined effect of restriction and malabsorption results in rapid and sustained weight loss. The direct contact of food with the small intestine results in release of hormones which increase the metabolic rate and burn fat. This not only decreases body weight but also helps in remission of metabolic diseases like diabetes and hyperlipidemia.

Bariatric Surgery

  1. Mini – It is combined procedure in which a long narrow gastric tube is created and joined directly to the mid portion of the small intestine. It differs from the classical RYGB in the size of the gastric pouch which is considerably larger and the diameter of the anastomosis between the pouch and the intestine which is also wider. As a result, the patient is able to eat larger portions of food than that possible after a RYGB. The main mechanism by which this procedure works is malabsorption due to delay in the mixing of food and digestive enzymes. It also results in effective excess weight loss of up to 80% with remission of comorbid diseases.

 

  1. Bilio pancreatic diversion with Duodenal Switch– It is a combined procedure which involves creating a tube of the stomach like that for a sleeve gastrectomy and bypassing around two thirds of the total length of the intestine for malabsorption. Although still being done widely in the western world, it has not gained popularity in Asia because of the malabsorptive side effects leading to diarrhea and protein malnutrition particularly when diet is deficient in protein. It leads to 80-90% of excess weight loss with excellent resolution of comorbid illnesses.

 

Malabsortive procedures include

 

  1. Jejunoileal bypass – It is purely a malabsorptive procedure which connects the proximal part to the small intestine to the terminal ileum decreasing the effective length for absorption of food. This procedure is not performed these days due to its side effects.