Who Would Have Thought It? An Operation Proves to Be the Most Effective Therapy for Adult-Onset Diabetes Mellitus

Abstract

ObjectiveThis report documents that the gastric bypass operation provides long-term control for obesity and diabetes. Summary Background DataObesity and diabetes, both notoriously resistant to medical therapy, continue to be two of our most common and serious diseases. MethodsOver the last 14 years, 608 morbidly obese patients underwent gastric bypass, an operation that restricts caloric intake by (1) reducing the functional stomach to approximately 30 mL, (2) delaying gastric emptying with a c. 0.8 to 1.0 cm gastric outlet, and (3) excluding foregut with a 40 to 60 cm Roux-en-Y gastrojejunostomy. Even though many of the patients were seriously ill, the operation was performed with a perioperative mortality and complication rate of 1.5% and 8.5%, respectively. Seventeen of the 608 patients (<3%) were lost to follow-up. ResultsGastric bypass provides durable weight control. Weights fell from a preoperative mean of 304.4 lb (range, 198 The operation provides long-term control of non-insulin-dependent diabetes mellitus (NIDDM). In those patients with adequate follow-up, 121 of 146 patients (82.9%) with NIDDM and 150 of 152 patients (98.7%) with glucose impairment maintained normal levels of plasma glucose, glycosylated hemoglobin, and insulin. These antidiabetic effects appear to be due primarily to a reduction in caloric intake, suggesting that insulin resistance is a secondary protective effect rather than the initial lesion. In addition to the control of weight and NIDDM, gastric bypass also corrected or alleviated a number of other comorbidities of obesity, including hypertension, sleep apnea, cardiopulmonary failure, arthritis, and infertility. 339

Endocrine mechanisms mediating remission of diabetes after gastric bypass surgery

“…In 1995, Pories et al 4 reported long term results from 608 severely obese patients who underwent gastric bypass, with a 93% follow-up rate over 14 years. Beyond achieving substantial, durable weight loss (37% of total body weight at 1 year and 30% at 14 years), these individuals experienced remarkable remission of T2DM.…”

“…4,5 In the landmark study, by Schauer et al 5 of 1160 patients undergoing RYGB, among the 240 with T2DM severe enough to be treated with oral medications and/or insulin, 30% were discharged from their initial surgical hospitalization with normal plasma glucose levels off all diabetes medicinesFafter an average hospital stay of only 2.8 days. Most of the remainder discontinued their diabetes treatments within a few weeks, and the eventual complete remission rate was 83%.…”

“…RYGB causes weight loss through gastric restriction and additional mechanisms involving changes in gut hormones and other processes under active investigation. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] RYGB and BPD produce the highest and most rapid rates of remission of type 2 diabetes mellitus (T2DM).…”

The nucleus tractus solitarius: a portal for visceral afferent signal processing, energy status assessment and integration of their combined effects on food intake

“…Analyses of large numbers of gastric-bypass cases show that on average, patients lose B35% of their pre-surgery body weight within the initial year and that 10 years post-surgery, the majority of the lost weight is not regained. 2,3 Recent attention to the factors contributing to the efficacy of bypass surgery focuses on the combination of increased circulating levels of the distal gut hormones glucagon-like peptide-1 (GLP-1) and peptide YY 3-36, as well as on the reduced stimulation of the 'bypassed' stomach and duodenum as causal in the clinical outcomes. Further support for the contribution of GI signals and their CNS-mediated effects to the physiological control of energy balance comes from the recent success of the GLP-1 analog, exendin-4 (Ex-4), a modified peptidaseresistant GLP-1 analog, in the treatment of type 2 diabetes and from the indications that this treatment also results in body weight loss.…”

Recent advancements in bariatric/metabolic surgery

“…Initiation of bariatric surgery for the treatment of T2DM started from the report by Pories et al. in 1995 82. Strong evidence has shown that bariatric surgery is an effective treatment for severe obesity (BMI >35 kg/m 2 ) and results in marked improvement of T2DM control 10, 83, 84.…”