Bariatric Times - August 2008 - (Page 10) 10 Surgical Perspective Bariatric Times • August 2008 Scopinaro in a series of 312 patients showed that BPD can reverse diabetes, hypertension, and hypercholesterolemia in morbidly obese patients, and this effect persisted up to 10 years after surgery.58 He reported resolution of diabetes as early as one month after BPD in diabetic obese patients, when the excess weight was still more than 80 percent.57 A biliopancreatic diversion was performed on two patients with diabetes and familial hypertriglyceridemia.The procedure was performed to better control the lipid disorder. The BMIs of the patients were 21 and 20. After surgery, the blood sugar normalized in the two patients. Bariatric surgery is also effective in curing diabetes in normal-weight subjects.59 Roux-en-Y gastric bypass (RNYGB). Rubino et al reported that after Roux-en-Y gastric bypass, insulin as well as GIP levels decreased to normal values in obese diabetic patients, whereas GIP increased slightly but not significantly in obese nondiabetic subjects.32 Cohen et al in a series of 37 patients with BMI of 32 to 35kg/m2 and poorly controlled comorbidities reported resolution of T2DM and dyslipidemia in 100 percent of patients and hypertension in 97 percent after laparoscopic RYGB.6 The improvement in insulin sensitivity after RYGP is due not only to weight loss, but also to the exclusion of the duodenum and jejunum from food transit, with the consequent modifications on enteroinsular axis.56 The second mechanism underlying the resolution of diabetes after RYGB is related to the restoration of the impaired GIP/GIP receptor axis.60 Surgery is the only treatment that achieves significant weight loss in the morbidly obese patient. Minimal invasive techniques allow performance of complex bariatric surgeries with minimal morbidity and mortality. This successful experience with bariatric surgery lead to the concept of metabolic surgery. Metabolic surgery is performed in nonobese patients with severe metabolic diseases. The surgical procedure consists of bypassing the proximal small bowel. Good results have been obtained in animal models. The only human experience is the result of small series of case reports. Encouraging short-term results have been reported. However, the safety and long-term effect of such procedures are not yet very well defined. Metabolic surgery is a new concept that will represent a new era of surgical procedures. REFERENCES 1. National Institutes of Health Consensus Development Conference. Gastrointestinal surgery for severe obesity. Am J Clin Nutr. 1992;55(2 Suppl):615S–619S. 2. Cohen RV, Schiavon CA, Rubino F. Duodenaljejunal bypass for the treatment of type 2 diabetes in patients with body mass index of 2234kg/m2: A case report of 2 cases. Surg Obes Rel Dis. 2007;3:195–197. 3. Dixon JB, O’Brien, Playfair J, Chapman L. Adjustable gastric banding and conventional therapy for type 2 diabetes. JAMA. 2008; 299:316–322. 4. Ponce J, Haynes B, Paynter S, et al. Effect of Lap-Band-induced weight loss on type 2 diabetes mellitus and hypertension. Obes Surg. 2004;14:1335. 5. Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg. 1998;22:936–946. 6. Cohen R, Pinheiro JS, Correa JL, Schiavon CA. Laparoscopic Roux-en-Y gastric bypass for BMI 35kg/m2: a tailored approach. Surg Obes Relat Dis. 2006;2:401–404. 7. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K: Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–1737. 8. Liebl A. Challenges in optimal metabolic control of diabetes. Diabetes Metab Res Rev. 2002;18(Suppl 3):S36–S41. 9. DeFronzo RA. Pharmacologic therapy for type 2 diabetes mellitus. Ann Intern Med. 1999;131:281–303. 10. Evans A, Krentz AJ. Benefits and risks of transfer from oral agents to insulin in type 2 diabetes mellitus. Drug Safety. 1999;21:7–22. 11. Deacon CF, Nauck MA, Toft Nielsen M, et al. Both subcutaneously and intravenously administered glucagon like peptide I are rapidly degraded from the NH2 terminus in type II diabetic patients and in healthy subjects. Diabetes. http://www.carecredit.com http://www.carecredit.com
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