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Diabesity : A Literature Review. By: Courtney Saia. Purpose Statement:. To determine whether Bariatric surgery is effective at eradicating Type 2 Diabetes Mellitus (T2DM). Diabetes:. T2DM affects more than 170 million people worldwide.

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purpose statement
Purpose Statement:
  • To determine whether Bariatric surgery is effective at eradicating Type 2 Diabetes Mellitus (T2DM).
diabetes
Diabetes:
  • T2DM affects more than 170 million people worldwide.
  • Limited success has been reached in the treatment of diabetes.
  • Estimated that the number of individuals living with diabetes will increase to 365 million worldwide by 2030.
  • People with Diabetes are more likely to have: cardiovascular, renal and ophthalmic comorbidities.
obesity
Obesity:
  • World Health Organization (WHO) estimates more than 1.6 billion people are overweight, 400 million are obese.
  • More than 77 million American adults are obese.
  • The literature suggests diet and exercise combined along with weight reduction medications does not result in durable weight loss for obesity.
diabesity
Diabesity:
  • Due to the substantial link between T2DM and obesity the coining of the word Diabesity has been prompted.
bariatric surgery
Bariatric Surgery:
  • Typically results in sustained weight loss and durable glycemic control.
  • A surgery performed on the stomach and/or intestines in an effort to help an individual with obesity lose weight.
  • Four types of procedures:
    • Laparoscopic Adjustable Gastric Banding (LAGB)
    • Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
    • Sleeve Gastrectomy (SG)
    • Roux-en-Y Gastric Bypass (RYGB)
bariatric surgery appropriateness criteria
Bariatric Surgery: Appropriateness Criteria
  • Age:
    • Male: ≥ 45 years
    • Female: ≥ 55 years
  • BMI: ≥ 35
  • Severity of obesity-related comorbidities:
    • Established coronary heart disease
    • Other atherosclerotic diseases
    • T2DM
    • Sleep apnea
    • Stroke
    • Cancer
    • Osteoarthritis
    • Gallstones
    • Stress incontinence
    • Gynecological abnormalities
laparoscopic adjustable gastric banding lagb
Laparoscopic Adjustable Gastric Banding (LAGB):
  • Restrictive Operation
  • Rigid, plastic band with a saline filled rubber, balloon lining is used.
  • Band is placed around the upper section of the stomach (below the gastroesophageal junction).
  • Flexible tubing is connected from the band to a port on the outside of the body.
    • Port allows for the surgeon to adjust the saline content of the band by a hypodermic needle.
sleeve gastrectomy sg
Sleeve Gastrectomy (SG):
  • Restrictive Operation.
  • 10-14 mm is placed along the right side of the stomach.
  • Surgical stapler is fired adjacent to the tube until the left side of the stomach is completely restricted  banana-shaped stomach (holds ≈ 150-200 mL)
  • Decreases ghrelin levels.
biliopancreatic diversion with duodenal switch bpd ds
Biliopancreatic Diversion with Duodenal Switch (BPD-DS):
  • Restrictive and Malabsorptive Operation
  • Sleeve Gastrectomy (SG) provides the restriction.
    • Large portion of the small intestine is bypassed  150-200 cc gastric sleeve which is connected to the remainder of the small intestine
  • Excluded portion of the small intestine is attached 100 cm to the ileocecal valve.
    • Serves as the conduit for bile and pancreatic juices
roux en y gastric bypass rygb
Roux-en-Y Gastric Bypass (RYGB):
  • Primarily performed laparoscopicaly through 5-7 trocar sites.
  • Surgical stapler creates a small, stomach pouch.
    • Containing only food particles.
  • Bowel beyond the stomach pouch contains both food particles and digestive juices.
methods
Methods:
  • The following databases were used:
    • CINAHL, Web of Knowledge, Medline, Google Scholar
  • The terms “bariatric surgery” and “diabetes treatment” were entered.
  • To limit the search Boolean logical operators, source type, date of publication, language, study participants, and the truncation of terms were used.
  • A total of 27 articles were referenced
resolution of diabetes after lagb
Resolution of Diabetes after LAGB:
  • Dixon et al.
    • 50 participants with T2DM, followed for 1 year post-operative
    • Remission of T2DM was defined as (normal HbA1c levels, without pharmaceutical therapy).
    • Results:
      • 64% of participants achieved T2DM remission
      • 26% noted improvement in glycemic control
      • 10% remained unchanged
resolution of diabetes after lagb1
Resolution of Diabetes after LAGB:
  • Dixon: Later Study
    • Randomized-controlled study
    • Intervention:
      • LAGB (experimental group) or diet and exercise (control group)
    • Results:
      • 73% of participants who received LAGB demonstrated T2DM remission.
      • 13 % of the participants in the control group demonstrated T2DM remission.
resolution of diabetes after lagb2
Resolution of Diabetes after LAGB:
  • Ponce et al.
    • 402 LAGB patients were reviewed.
    • Preoperatively 53 out of the 402 patients were on hypoglycemic medication for T2DM
    • Results:
      • T2DM resolution in 66% of patients at the 1 year mark
      • T2DM resolution in 80% of patients at the 2 year mark
resolution of diabetes after bpd ds
Resolution of Diabetes after BPD-DS:
  • Scopinario
    • Looked at 2,241 BPD patients and determine 100% of those of T2DM had resolution (4 months postoperative)
  • Scopinario: 2008 Study
    • Comparison of RYGB and BPD.
    • Data from 443 patients with T2DM between the years of 1976 and 2007 were collected
    • Results:
      • 75% of patients were in remission 2 months postoperative.
        • Remained stable for almost a 20 year period
resolution of diabetes after sg
Resolution of Diabetes after SG:
  • University of Pittsburgh (2006):
    • 126 patients
    • Results:
      • 1 year postoperative, 81% of SG patients demonstrated T2DM resolution; 10% showed significant improvement.
  • Italian Study:
    • 44 SG patients
    • Results:
      • 76% of participants showed T2DM resolution during 19 year follow up
      • T2DM improvement was reported in 15% of patients
resolution of diabetes after rygb
Resolution of Diabetes after RYGB:
  • Pories
    • 608 RYGB patients (121 had T2DM and 150 had impaired glucose tolerance)
    • Patients were followed for 14 years postoperatively.
    • Results:
      • 83% of the 121 T2DM patients experienced resolution.
      • 98% of the 150 with impaired glucose tolerance maintained normal levels.
resolution of diabetes after rygb1
Resolution of Diabetes after RYGB:
  • Swedish Obese Subjects Study Group:
    • 2004 report included 4,047 postoperative subjects followed for 2 years and 1,703 for 10 years.
    • Results:
      • T2DM recovery was reported in 72% of RYGB patients compared to 21% resolution in the medical management group.
limitations
Limitations:
  • Many of the studies were uncontrolled case studies with a few being randomized controlled trails.
possible theories of resolution
Possible Theories of Resolution:
  • While the results of the studies were statistically significant, the pathophysiology of the T2DM resolution is not understood.
  • Combination of weight loss, decreased caloric intake, intestinal malabsorption, hormonal changes, and rearrangement of the gastrointestinal anatomy
effect of bariatric surgery on t2dm
Effect of Bariatric Surgery on T2DM:
  • All bariatric surgical procedures induce decreased caloric intake, which has a well established beneficial effect on T2DM.
  • Glucose homeostasis improves more rapidly after segments of the small bowel are bypassed when compared to restrictive procedures
most intriguing fact
Most Intriguing Fact:
  • Weight loss does not appear to be the primary mechanism for T2DM resolution after RYGB and BPD-DS.
    • Most studies noted T2DM resolution occurs within days after surgery before any significant weight loss has occurred.
further research
Further Research:
  • Randomized clinical trials comparing surgical and medical therapies for T2DM are needed.
    • Due to increasing numbers of diabetes patients undergoing bariatric surgery.
  • Bariatric surgical procedures should be incorporated into a national clinical registry.
    • Enable objective assessments of the risk and benefits.
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