Bariatric Times - December 2008 - (Page 16)

16 Diabetes Perspective Bariatric Times • December 2008 FIGURE 1. Duodenal jejunal bypass as first proposed (initial protocol): Intact stomach and 50cm biliary limb and 80cm alimentary limb. the gastric fundus—may lead to a swifter gastric emptying. Preserving the pylorus is likely to be very important in decreasing the glycemic peaks after food ingestion, leading to a better first phase insulin response and better glycemic outcomes. primary mediator in the surgical control of diabetes. The same outcomes have been reported in humans in investigational trials. These findings raise the possibility that putative mechanisms from the proximal small bowel may be implicated in the pathophysiology of T2DM. Together, these data suggest a novel revolutionary concept about an old disease: T2DM may be an operable intestinal illness. IS BMI AS IMPORTANT AS THOUGHT? There is no doubt that the findings described here are a strong paradigm shift in the treatment of patients with diabetes. In our series, there have been strong responders—as mentioned, these are patients without either insulin or medications who actually regained weight after surgery, but are still diabetes-free. In fact, BMI alone is not an ideal tool to accurately evaluate the risk–benefit ratio in patients with diabetes. Presently, there is no scientific evidence that a clear BMI threshold can distinguish between patients for whom surgery can resolve diabetes and patients in whom surgery would be ineffective. REFERENCES 1. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care. 1998;21:1414–31. Pories WJ, MacDonald KG, Morgan EJ, et al. Surgical treatment of obesity and its effect on diabetes: 10-y follow-up. Am J Clin Nutr. 1992; 55 (2 Suppl):582S–585S. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and metaanalysis. JAMA. 2004;292:1724–1737. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339–352. Cohen R, Pinheiro JS, Correa JL, Schiavon CA. Laparoscopic Roux-en-Y gastric bypass for BMI<35kg/m2: a tailored approach. Surg Obes Rel Dis. 2006;2:401–404. Cummings DE, Overduin J, Foster-Shubert KE, Carlson M. Role of the bypassed proximal intestine in the antidiabetic effects of bariatric surgery. Surg Obes Rel Dis. 2007;3:109–115. Rubino F, Forgione A, Cummings DE, et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg. 2006;244:741–749. Strader AD, Vahl TP, Jandacek RJ, et al. Weight loss through ileal transposition is accompanied by increased ileal hormone secretion and synthesis in rats. Am J Physiol Endocrinol Metab. 2005;288:E447–E453. Troy S, Soty M, Ribeiro L, et al. Intestinal gluconeogenesis is a key factor for early metabolic changes after gastric bypass but not after gastric Lap-Band in mice. Cell Metabolism. 2008;8:201–211. Cohen R, Schiavon CA, Pinheiro JC, et al. Duodenal-jejunal bypass for the treatment of type 2 diabetes in patients with body mass index of 22–34 kg/m2: a report of two cases. Surg Obes Relat Dis. 2007;3:195–197. 2. 3. 4. 5. 6. 7. CONCLUSIONS Conventional gastrointestinal operations for morbid obesity have been shown to dramatically improve T2DM, resulting in normal blood glucose and HbA1c levels with discontinuation of all diabetesrelated medications or insulin. Often, the return to fasting euglycemia and normal levels of postprandial and regular insulin levels are observed within days or weeks after surgery, suggesting that weight loss alone cannot entirely explain why surgery improves diabetes. Although there is clear and rapid amelioration of diabetes symptoms, the withdrawal of medication and insulin has to be balanced and slow. Recent experimental studies illustrate that the rearrangement of the gastrointestinal anatomy is a 8. 9. 10. AUTHOR CORRESPONDENCE: Ricardo Cohen, MD, Center for the Surgical Treatment of Morbid Obesity and Metabolic Disorders, Baros Surgical Associates, Rua Padre João Manuel, 222 cj 131 01411-000 São Paulo, Brazil; E-mail: rvcohen@attglobal.net. http://www.newdirectionsystem.com http://www.newdirectionsystem.com

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Bariatric Times - December 2008 Table of Contents Patient Management Perspective Diabetes Perspective Interview: ASMBS’s Georgeann Mallory Editorial Message Editorial Board Body Contouring Perspective Meeting Perspective Journal Watch Advertiser Index News & Trends

Bariatric Times - December 2008

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