Download BARIATRIC SURGERY FOR TREATMENT OF TYPE 2 DIABETES

Ivaylo Tzvetkov, Krasimir Shopov,
Jordan Birdanov, Ivan Jurukov Hospital Doverie,
Sofia, Bulgaria
Background
• According to recent studies obese patients with type II diabetes
who undergo bariatric surgery revert to normal blood glucose
and insulin levels and develop a dramatic increase in insulin
sensitivity.
• However, the mechanisms involved are unknown.
• The Bariatric procedures, which develop such a rapid decrease
in blood glucose and insulin levels are the malabsortive
procedures as gastric by pass, duodenal switch and biliopancreatic diversion.
• Laboratory studies with diabetic rats, which underwent bariatric
procedures showed improved glucose tolerance and decreased
fasting blood glucose.
Background
• Type II diabetes continues to be associated with high
rates of morbidity and mortality, leading to both
financial and social burdens.
• Obese patients has normal blood glucose, glycosylated
hemoglobin and insulin levels and fourfold increase in
insulin sensitivity without continuation of diabetic
medication 2 to 4 weeks after Bariatric surgery.
• Bariatric surgery is going to be more aggressive in the
last five years and attempts to apply that kind of surgery
even to patients with BMI of 30 kg/m2.
Background
• Bariatric surgery for type 2 diabetes must be performed
within accepted international and national guidelines.
This requires appropriate assessment for the procedure
and comprehensive and ongoing multidisciplinary care,
patient education, follow-up and clinical audit, as well as
safe and effective surgical procedures. National
guidelines for bariatric surgery in people with type 2
diabetes and a BMI of 35 or more need to be developed
and promulgated.
Classification
Principal cut-off points
Cut-off points for Asians
Normal range
18.5 - 24.9
18.5 - 22.9
23.0 - 24.9
Pre-obese
25.0 - 29.9
25.0 - 27.4
27.5 - 29.9
Obese class I
30.0 - 34.9
30.0 - 32.4
32.5 - 34.9
Obese class II
35.0 - 39.9
35.0 - 37.4
37.5 - 39.9
Obese class III
≥40.0
≥40.0
• The aim of the study is to reveal initial experience with
Surgical Treatment of Type 2 Diabetes in patients with
BMI over 35 kg/m.
• We tried to compare the effect of the main types of
bariatric procedures:
- restrictive as vertical gastroplasty by Champion
technique and Sleeve gastrectomy
- malabsortive procedures as Gastric by pass
on Diabetes type II in those patients and influence of
surgery over the metabolic control of diabetes and its
associated risk factors.
• Two types of restrictive Bariatric surgical
procedures were done:
- Vertical Gastroplasty by Champion technique
- Sleeve Gastrectomy
• The malabsortive procedure was Gastric antecolic
Mason type by pass.
• All surgical procedures were done laparoscopically
– key hole surgery with short stay after operations
and fast recovery.
• Selection of patients was done to following
criteria:
- BMI over 35kg/m
- moderate or well controlled Diabetes type 2
with oral or on insulin therapy
- controlled co-morbidity as arterial
hypertension, sleep apnea, reflux disease
- lack of alcohol abuse or severe mental
disorders
- contraindications for general anesthesia
• 36 patients with Diabetes type 2 and Morbid Obesity
were included in the study.
• Preoperative assessment included:
- blood sugar control for 24 hours before surgery, the
same control on 1st and 3rd week after surgery, follow up
of blood sugar 3,6 and 12 months after Bariatric Surgery
• Preoperative assessment of glycosylated hemoglobin and
insulin levels 2 weeks before surgery. Their values
6,12,36 and 48 months after surgery were also followed
up.
• 29 patients underwent Laparoscopic Gastric bypass surgery.
There were no major complications in that group and all were
discharged within 5 days after the operation.
• Laparoscopic Sleeve Gastrectomy was done in 5 female
patients aged from 51 to 60. There was only one complication
in a 54 years old woman but recovery and outcome were
uneventful.
• LaparoscopicVertical Gastroplasty by Champion technique was
applied in 2 cases, one male and one female patients with BMI
between 39 and 43kg/m2. There were no complications in those
cases and patients were discharged 4 days after surgery.
• About 26 patients had inadequate controlled Diabetes type 2
one month before surgery with mild raised values of blood
sugar and HbA1c was between 8 and 11% in 14 of them.
• 21 patients were on Insulin therapy before surgery and the other
15 patients on oral treatment and diet.
• Insulin blood levels were raised in 28 patients before surgery.
• About 34 patients had 1 month before surgery poorly to
controlled arterial hypertension.
• All 36 patients had reflux disease with mild symptoms as
regurgitation and heart burning, 11 of them had also hiatal
hernias type I found on preoperative upper endoscopy and
barium X-rays investigations
• Sugar blood tests showed significantly drop off 1 week after
surgery in 31 patients. They had results from 5,1 to 7,4 mmol/l
• The other 5 patients had sugar blood results from 7,0 to 8,5
mmol/l in the first postoperative week and only in 2 patients
with Vertical Gastroplasty sugar blood levels remained between
6,5 to 7,2 mmol/l one year after surgery.
• The results of HbA1c dropped to 6,0- 7,0% in 2 to 3 months
after surgery and remained on that levels in 33 patients 1 year
after surgery.
• Insulin levels were normal in all patients 3 to 6 months after
surgery.
• 34 patients did not need any medical treatment about Diabetes type 2
within 15 to 18 months after surgery.
• The other two patients were only on oral therapy and diet for
treatment of Diabetes type 2.
• The blood pressure was normal in 27 patients 6 months after surgery.
The other 9 patients reduced oral intake of medications for that comorbidity significantly (p> 0,05).
• About 14 patients had improvement of arterial blood supply of lower
limbs 4 to 6 months after bariatric surgery done by doppler duplex
scan.
• The quality of life in all patients was assessed by themselves with 8
to 10 points according to VAS 6 months to 1 year after surgery
Remission based on fasting plasma
glucose <7.0 mmol/l and not on
hypoglycaemic therapy
After Bariatric
Malabsortive
Surgery
Control Group with Lap-Band
and Vertical Gastroplasty
2-year incident
0,5 %
2,5%
4-year incident
2,0%
4,5%
2-year remission
92%
68%
4-years remission
75%
46%
• Our data supports recent investigations and multi-central
studies about recommendations for surgical treatment of
morbid obese patients with BMI over 35kg/m2 and
Dabetes type 2.
• Laparoscopic Bariatric surgery has a history of more
than 15 years with good outcome and low rate of
complications as in laparoscopic cholecystectomy.
• LRYGB procedures influence the gut hormonal milieu
and provide an early non-weight related improvement in
glycaemic control of type 2 diabetes according to our
study.
• Diabetes type 2 remits or improves in the majority of patients after
bariatric surgery. The procedures producing greater excess weight loss as
Gastric bypass and Sleeve Gastrectomy lead to higher remission rates.
• We need a Bulgarian official survey and consent between surgeons and
endocrinology specialists to establish national guidelines for treatment of
Morbid obese patients with Diabetes type 2.
• The societies of Bulgarian surgeons and endocrinology specialists have to
make further steps to inform the society and Ministry of Health that
surgical treatment of Diabetes type 2 is not a myth or an experiment with
commercial issues as it was said a year ago by a representative of the
National Health Insurance Fund but a medical based evidence for a new
treatment option of Diabetes type 2 all over the world.
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HbA1c <6,0%
No hypoglycaemia
Total cholesterol < 4 mmol/l, LDL cholesterol < 2 mmol/l
Triglycerides <2,2 mmol/l
Blood pressure < 135/85 mmHg
Over 15% weight loss
• With reduced medication from the pre-operated state or without
other medications (where medications are continued, reduced
doses from pre-surgery with minimal side effects would be
expected)
Thank you for your
attention
Ivaylo Tzvetkov, Krasimir Shopov,
Jordan Birdanov, Ivan Jurukov Hospital Doverie,
Sofia, Bulgaria