Gastrointestinal surgery has for many years been offered to patients for management of obesity. A variety of surgical techniques have been developed including the 4 most commonly used procedures.

Adjustable Gastric Banding (AGB),
Gastric Bypass (RYGB),
Gastric Sleeve (GS).
Biliary-Pancreatic Diversion (BPD)

This is known as Bariatric surgery. It promotes weight loss by changing the gastrointestinal anatomy and limiting the amount of food that can either be eaten (restrictive) or (malabsorptive).

The Adjustable Gastric Band is clearly a restrictive procedure and the Biliary-Pancreatic Diversion principally a malabsorptive procedure. Mixtures of both restrictive and malabsorptive procedures are nowadays commonly in use. When reviewing data regarding either weight control or diabetes remission with surgery it is necessary to identify the exact procedure used in the study in question.

Results for weight loss following Bariatric surgery have been spectacularly good. They compare much more favorably than trials with conventional medical drug treatment for weight loss. Diabetic patients who have undergone bariatric surgery for weight loss have been noted to demonstrate a remission in their diabetes soon after the procedure. The remission rates have been over 80% in some clinical trials. The question is whether you would be prepared to take such a drastic step, what are the perioperative complications and how successful or detrimental are these procedures in the long-term.

Making sense of the different Surgical Techniques.

Long-term randomized clinical trials are needed before the success of any operation can be assessed. There is currently limited information because the field is in its infancy. There is now some good literature in this field providing results of more than ten years of follow up relating to the four main types of operative procedure.

All four procedures have positive results regarding sustained weight loss. All four procedures have been shown to improve diabetes control to the point of demonstrating a substantial remission rate when compared to conventional medical therapy.

Adjustable Gastric Banding (AGB).

This is considered the safest procedure as it is minimally invasive. An adjustable gastric band can be applied around the upper part of the stomach and therefore restrict the amount of food that is possible to consume at any one time. There is no permanent anatomical change and the procedure is reversible. The surgery is relatively straightforward and can be applied in an outpatient setting with minimal analgesia.

The results for weight loss are good, sustainable and accompanied by improvements in diabetes control. It is however very operator dependent. There are some poor results from some centers and some very good ones from other centers. The key here is to choose your surgeon carefully and make sure that follow up has been comprehensively planned. Success is very much linked to follow up where adequate band tightening can be assessed at intervals.

Gastric Bypass (RYGB).

The standard gastric bypass is the Roux-en-Y gastric bypass and referred to as the RYGB. In this irreversible procedure a small stomach pouch is created and then connected to the distal small intestine. The upper part of the intestine is reconnected in a Y shaped configuration.

There is a risk of malabsorption and of symptoms due to dumping of food straight into the intestine. The results of long-term weight loss, remission of diabetes and improved cardiovascular health have been impressive.

Sleeve Gastrectomy (SG).

A sleeve gastrectomy is also referred to as the gastric sleeve. During this procedure the stomach is significantly reduced in size by slicing out a major curve. The open edges are then stapled or sutured up leaving the remaining small sleeve like structure to restrict the amount of food that is possible to eat. There are many variations on a theme with this type of surgery including adding forms of intestinal bypass to the basic operation.

Results have been promising with respect to sustained weight loss and remission of diabetes. If intestinal bypass is avoided the problems associated with malbsorption are much less relevant. The hormonal changes which stimulate insulin secretion and which seem so beneficial after gastric bypass also seem to occur after sleeve gastrectomy. This makes the SG procedure particularly attractive to diabetic patients who are concerned about the malabsorptive complications associated with any form of intestinal bypass procedure.

Bilio Pancreatic Diversion (BPD).

Biliopancreatic diversion (BPD) is the classical malabsorptive operation. The stomach is refashioned and connected to the small intestine and thereby bypassing the duodenum and jejunum.

A BPD with a duodenal switch (DS) where there is gastric reduction and re-plumbing of the upper and lower small intestinal elements is both a restrictive and malabsorptive procedure. The anatomical arrangement allows for a selective limitation of fat absorption and therefore a severe limitation of calorie intake.

There are excellent results for sustained weight loss and diabetes remission rates with these procedures. Severe malabsorption and nutritional deficiency can complicate this procedure and life long follow up is necessary to assess for this possibility.

Choosing the right operation for you.

Careful patient selection is a very important part of the process. The significant factors that influence the success of the procedure include dietary patterns, psychological approaches to food behavior and other associated medical disorders.

Follow up at regular intervals after the surgical procedure is of paramount importance. If this proves to be difficult or impossible then surgery should not be entertained. Flow up is essential for the completion of the clinical trial data as well as ensuring assessments for possible complications.

With respect to choosing the most relevant surgical operation it would be most worthwhile to identify your diabetes and surgical team with care. Most procedures are operator dependent with different skills perfected in different centers of excellence. The multidisciplinary team approach will identify the most relevant surgical procedure based on a whole variety of factors.

For your own decision making process you will need to document an analysis of perioperative complications, the preparation necessary for surgery, the length of hospital stay and immediate follow up plans. The immediate dietary changes will need to be established as well as a dietary plan for the longer-term. Detailed knowledge of future assessments and contact details in case of complications must be clearly documented.

Best Surgical Option for Obese Type 2 Diabetes.

This is not an easy question to answer because of the lack of long-term data. Currently available data generated over the past 10 year period shows that all four main procedures do well for sustained weight loss and diabetes remission. There is also good evidence that bariatric surgery improves cardiovascular risk and in the long-term reduces cardiovascular events such as heart attack and stroke.

Published results comparing gastric banding versus conventional medical treatments favors the surgical approach. As with all these studies the definition of diabetes remission needs some consistency. Its absence contributes to confusion in reporting the data but in general diabetes remission rates are very significantly improved in most studies.

Of the surgical possibilities, recent reviews by P. Schauer of the Cleveland Clinic suggest that the Gastric bypass (RYGB) offers consist advantages weight loss and better diabetes remission rates than the gastric band. Sleeve Gastrectomy and BPD procedures also demonstrate excellent figures in diabetes subjects.

Best Surgical Option for Non-Obese Type 2 Diabetes.

The best surgical operation for a non obese diabetic subject wishing to consider a procedure to put diabetes into remission has yet to be established. This is still the big question that still needs to be answered before the field of Bariatric surgery can justifiably claim to have entered a new era of true Metabolic surgery.

Metabolic Surgery

Since there is now adequate evidence that Bariatric surgery can be associated with a high remission rate of diabetes the surgical techniques have come under review as treatment options in their own right. This is referred to as metabolic surgery because the primary indication is to reverse or improve diabetes control.

Most surgery is currently performed on obese diabetic patients. This can be regarded as 'Bariatric and Metabolic Surgery' because there will be weight loss as well as improvements in diabetes control. The question at the moment lies with the possible use of surgery in only mildly overweight diabetic patients or even on normal weight patients. This would be true 'metabolic surgery' because the indication for doing is to influence the diabetes management and possibly putting it remission rather than weight loss.

How does Metabolic Surgery work?

The medical research investigating why surgical methods reduce blood glucose levels immediately after the surgery has shown that this occurs even before any obvious changes in body weight. There are changes in gastrointestinal hormones after surgery and this leads to much more efficiently functioning pancreas after the procedure. The incretin hormones such as GLP-1 are powerful stimulators of insulin secretion and the level of these hormones rise after bariatric and metabolic surgery

Because the remission rates of Type2 diabetes are very impressive, metabolic surgery is likely to become a major player in diabetes treatment programs in years to come.

Who should be offered metabolic Surgery?

The weight or Body Mass Index (BMI) thresholds guiding who can get treated are currently being revised. This is likely to result in diabetic patients who are not obese being offered surgery. The BMI guidelines may in fact hinder expansion in this field. It has been argued that because the results are so spectacular after metabolic surgery that a much wider range of diabetic patients should be eligible regardless of whether they are obese or not.

The current guidelines of the US National Institute of Health recommend bariatric surgery for people with a BMI of over 40 and a BMI over 35 if there are comorbidities such as Type 2 diabetes. There are other professional bodies (such as the American Society for Metabolic and Bariatric Surgery (AMSMB) whose guidelines now suggest that any patient with a BMI of more than 30 with Type 2 diabetes should be a candidate for metabolic surgery. A lowering of the benchmark is what seems to be happening with time.

It should be remembered that the BMI is quite a poor indicator of long-term morbidity. The waste-hip ratio is a much better indicator of abdominal obesity and it is this which appears to trigger inflammation and vascular disease. In addition there are some ethnicities where vascular disease sets in at a much lower BMI. People from Asia are one such group. Focusing on BMI may be missing the point if the goal is to influence and prevent vascular disease with weight management.

Adapting the BMI guidelines to control which diabetes patients should eligible for surgery may compound the problem. This is because many patients in the lower BMI brackets could benefit enormously from metabolic surgery. Many of these patients may also present with an adverse cardiovascular risk profile and these may be the very patients who will benefit most from metabolic surgery.

The Future and new Metabolic Techniques.

The explosion of possible surgical approaches for both weight loss and diabetes remission represents the major area of interest in this field. There are many variations on the main theme such as for example omega loop gastric bypass. Laparoscopic Gastric Plication is an alternative method to limit food intake into the stomach. It involves sewing folds in the stomach and thereby reducing stomach volume without the need for cutting or stapling the stomach. This procedure is minimally invasive. Further information regarding many of the procedures on offer can be obtained from the many available websites. (weightloss.clevelandclinic.org)

Another promising technique is the endoscopically placed endobarrier. This is a tube which is place at the pyloric end of the stomach and which extends down into the small intestine. Food can pass down inside the tube but no absorption can take place along its length. Weight loss results are very good except for the fact that the technique has to be considered a temporary measure. The tube is commonly only placed for a period of 3 to 6 months with a maximum of 12 months. There is a high incidence of the anchoring mechanism failure with subsequent need for the endobarrier to be removed.

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