Surgery News - February 2009 - (Page 18) 18 GENERAL SURGERY FEBRUARY 2009 • SURGERY NEWS Weigh Diabetes-Related Risks of Bariatric Surgery B Y J E F F E VA N S Else vier Global Medical Ne ws ariatric surgery procedures in patients with type 2 diabetes affect the hormones that control insulin secretion and sensitivity, and these effects must be taken into consideration to maintain postoperative glycemic control, according to a review of bariatric surgery studies that reported diabetesrelated outcomes. “Caloric intake is minimal after any bariatric procedure, and patients are at high risk for hypoglycemia if their preoperative regimens are not appropriately adjusted,” wrote Dr. Marion L. Vetter and her associates at the University of Pennsylvania, Philadelphia (Ann. Intern. Med. 2009;150:94-103). Bariatric procedures that have been broadly classified as malabsorptive, such as biliopancreatic diversion (BPD) with duodenal switch, have reportedly had a greater effect on the gastrointestinal hormones known as incretins (which stimulate insulin release after enteral nutrition) than do so-called restrictive procedures, such as laparoscopic adjustable gastric banding (LAGB) and vertical banded gastroplasty (VBG). Roux-en-Y gastric bypass (RYGB), which Dr. Vetter and her colleagues called the “current gold standard treat- B ment for severe obesity,” incorporates both malabsorptive and restrictive properties. In one large meta-analysis of bariatric studies, type 2 diabetes resolved in 84% of patients after RYGB, in 98% of patients after BPD, and in 48%-72% of patients after LAGB or VBG. Diabetes resolution seemed to be predicted across techniques according to body-mass index, sex, preoperative hemoglobin A1c, MALABSORPTIVE PROCEDURES REPORTEDLY HAVE HAD A GREATER EFFECT ON GASTROINTESTINAL HORMONES THAN HAVE ‘RESTRICTIVE’ PROCEDURES. and duration of diabetes. Dr. Vetter and her colleagues found that decreased caloric intake has an immediate impact on insulin sensitivity but does not alone account for lower blood glucose levels. Studies have shown that complete diabetes resolution occurs within days of intestinal bypass procedures but takes months to occur after LAGB. Even with the same postoperative caloric intake, blood glucose levels have been shown to drop further and faster after RYGB than after VBG. Changes in the levels of the incretins called glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP), as well as the levels of non-incretin gut peptides known as peptide YY (PYY) and ghrelin, appear to occur rapidly after gastric bypass. GLP-1, which is released by special cells of the distal ileum, is known to slow gastric emptying. It acts on pancreatic β islet cells to augment glucose-dependent insulin secretion and on the central nervous system to induce satiety and decrease food intake. GLP-1 remains elevated for 1 year after gastric bypass, but restrictive procedures do not change GLP-1 levels, in part because they do not alter gastric emptying. GIP is secreted by cells in the proximal gut and also acts on β islet cells to increase insulin secretion, but it is less potent than GLP-1 and does not affect gastric emptying or satiety. Lower levels of GIP have been reported several months after RYGB, but this has not been a consistent result. Specialized cells in the distal ileum produce PYY, which increases satiety and delays gastric emptying, increases as early as 2 days after RYGB, and remains elevated for at least 6 weeks, which “may account for the immediate decrease in appetite after surgery,” the researchers wrote. The response of PYY is blunted after meals in gastric banding patients, but no other studies have been published about its level in the weeks after banding or other restrictive procedures. Ghrelin is released from the gastric fundus and proximal small intestine to increase appetite by acting on the hypothalamus. Reports of the effect of gastric bypass on ghrelin levels have been inconsistent. Such studies may have included subtle variations in surgical technique that may have affected ghrelin levels. Because insulin requirements often rapidly decline after bariatric surgery, Dr. Vetter and her coauthors suggested that “patients may require only longacting basal insulin in the immediate postoperative period, with rapid-acting insulin for correction of hyperglycemia as necessary.” Rapid-acting insulin can be used for prandial coverage when patients resume eating, but they recommended avoiding sulfonylureas and meglitinides until patients begin eating regularly. Barring any contraindications, the researchers said that thiazolidinediones are safe once regular eating is occurring. Dr. Nayyar Iqbal, the senior author, is employed by Bristol-Myers Squibb. No other authors reported potential financial conflicts of interest. 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Table of Contents Feed for the Digital Edition of Surgery News - February 2009 Surgery News - February 2009 Contents The 20/20 Vision ICD-10 Looms News From the College: MedPAC Flak Oncology: Best for Breast General Surgery: Weighty Problem Surgery News - February 2009 Surgery News - February 2009 - Contents (Page 1) Surgery News - February 2009 - Contents (Page 2) Surgery News - February 2009 - Contents (Page 3) Surgery News - February 2009 - Contents (Page 4) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 5) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 6) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 7) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 8) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 9) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 10) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 11) Surgery News - February 2009 - Oncology: Best for Breast (Page 12) Surgery News - February 2009 - Oncology: Best for Breast (Page 13) Surgery News - February 2009 - Oncology: Best for Breast (Page 14) Surgery News - February 2009 - Oncology: Best for Breast (Page 15) Surgery News - February 2009 - Oncology: Best for Breast (Page 16) Surgery News - February 2009 - Oncology: Best for Breast (Page 17) Surgery News - February 2009 - Oncology: Best for Breast (Page 18) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 19) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 20)
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