The Enteroinsular Axis and the Recovery from Type 2 Diabetes after Bariatric Surgery

Department of Surgery, University of Perugia, Policlinico Monteluce, Via Brunamonti, 06122 Perugia, Italy.
Obesity Surgery (Impact Factor: 3.75). 06/2004; 14(6):840-8. DOI: 10.1381/0960892041590818
Source: PubMed


The Roux-en-Y gastric bypass (RYGBP) and the biliopancreatic diversion (BPD) induce long-term control of type 2 diabetes in morbidly obese individuals. The reasons for such an effect on glycemic metabolism are thought to be secondary to reduced food intake, weight loss and modifications of the enteroinsular axis which is impaired in type 2 diabetic patients. Both GLP-1 and GIP have an impaired secretin effect in type 2 diabetics, and surgery can restore this function. GIP is a peptide secreted by the duodenal K-cells in response to ingested fat and carbohydrate. In obese type 2 diabetes patients, its receptor on beta-cells is down-regulated. GLP-1 is a peptide secreted by the gut L-cells, and, in type 2 diabetes, its secretion is impaired. Both RYGBP and BPD provide durable GLP-1 delivery, both during fasting and after meal ingestion, inducing L-cell stimulation by early arrival of nutrients in the distal ileum. The secretion of GLP-1 influences glucose metabolism by inhibiting glucagon secretion, stimulating insulin secretion, delaying gastric emptying and stimulating glycogenogenesis. In conclusion, the early arrival of a meal in the terminal ileum seems to be the common feature of both operations that leads to an improvement in glycemic metabolism and to resolution of type 2 diabetes.

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    • "When bypassing down the jejunum or ileum, the secretion of incretin increases from the early stages (hindgut hypothesis) or insulin resistance decreases due to change of gastrointestinal hormone milieu (foregut hypothesis) [20,21]. Additionally, some researchers reported that these changes may induce the improvement of beta cell function [10,18-21]. "
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    ABSTRACT: The goals of this study are to evaluate the effect of duodenojejunal bypass (DJB) for type 2 diabetes mellitus (T2DM) patients below body mass index (BMI) 25 kg/m(2) in one year follow-up, and to compare the results of 1 week which we have reported in 2011. In this prospective observational study, there were 31 type 2 diabetic patients who underwent DJB at Inha University Hospital from July 2009 to January 2011. We did laboratories such as 75-g oral glucose tolerance test (OGTT), insulin level and hemoglobin A1c (HbA1c), etc. and compared their changes of preoperative, a week, 3 months, and 12 months. Mean BMI was 23.1 ± 1.3 kg/m(2), mean duration of T2DM was 8.3 ± 4.7 and mean age was 46.6 ± 7.7 years. There were a significant decrease of 75-g OGTT levels and increase of insulin secretion after 3 months. 13.3% showed diabetic remission (HbA1c < 6.0, medication cessation) and 26.7% showed diabetic improvement. The rates of remission and improvement much declined comparing with that of postoperative 1 week although those were determined by fasting and postprandial 2 hour level of glucose. This is the first study of metabolic surgery in Korean diabetes patients in the healthy weight range. DJB exerted positive influences on insulin resistance as well as beta cell function. Early effects on T2DM after DJB could be estimated as one of good modalities, although the effectiveness seems to be unacceptable. Further studies are mandatory for evaluation of the effectiveness of metabolic surgery and finding prognostic factors.
    Journal of the Korean Surgical Society 09/2013; 85(3):109-15. DOI:10.4174/jkss.2013.85.3.109 · 0.73 Impact Factor
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    • "Despite this, bariatric surgery has a remarkable beneficial effect on diabetes almost immediately after surgery and usually long before any significant weight loss occurs [8]. This has led to the theory of the entero-insular axis involvement in the resolution of diabetes in cases in which diabetes remission is independent of weight reduction [9]. Experimental studies in humans [10] [11] [12] suggest that certain bariatric procedures may improve diabetes control through mechanisms other than weight loss [13]. "
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    ABSTRACT: Background The question of whether pure metabolic surgery could be used in nonobese patients with type 2 diabetes has been considered. The objective of this study was to assess the comparative effects of the Billroth I (BI) and Billroth II (BII) reconstruction methods on remission of type 2 diabetes in nonobese patients undergoing subtotal gastrectomy for cancer. Methods The charts of 404 patients who underwent radical subtotal gastrectomy for cancer between January 2008 and December 2010 were retrospectively reviewed. From these patients, 49 with type 2 diabetes were included in this study. Diabetes remission rates, the percentage change in fasting plasma glucose levels, glycated hemoglobin levels, body mass index, and fasting total cholesterol levels at 2 years were observed. Outcomes were compared using propensity scores and inverse probability-weighting adjustment that reduced treatment-selection bias. Covariate-adjusted logistic regression models were assessed. Results The 2-year diabetes remission rate for the 23 patients who underwent BI reconstruction was 39.1%, compared with 50.0% for the 26 patients who underwent BII reconstruction. At 2 years, the BII group showed lower glycated hemoglobin levels (BI, 6.4%; BII, 6.1%; P = .003) and had greater percent reductions in their average glycated hemoglobin levels from baseline (BI,−11.6%; BII,−14.5%; P = .043). BII reconstruction was significantly associated with an increased diabetes remission rate (odds ratio, 3.22; 95% confidence interval, 1.05–9.83) in covariate-adjusted logistic regression analysis. Conclusions These propensity score-adjusted analyses of patients who had undergone subtotal gastrectomy indicated that BII reconstruction was associated with increased diabetes remission compared with BI reconstruction during the 2-year follow-up period. This study suggests the possibility of employing the surgical duodenal switch for the treatment of nonobese type 2 diabetes patients.
    Surgery for Obesity and Related Diseases 01/2013; 10(2). DOI:10.1016/j.soard.2013.09.013 · 4.07 Impact Factor
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    • "The idea is based on the observation of the postoperative course of bariatric patients. Several studies have documented remission of T2DM in 47–70% of cases after restrictive procedures, 80–98% after RYGB, and a rate as high as 92–100% after biliopancreatic diversion (BPD) [4]. "
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    ABSTRACT: The idea of surgery as treatment for type 2 diabetes mellitus (T2DM) was established in the US and was based on observation of patients after bariatric surgery. Resolution of T2DM is observed within a few weeks after surgery, in some cases even during hospitalization. The aim of this study was to evaluate the impact of Roux-en-Y gastric bypass (RYGB) on diabetes in morbidly obese patients. We present 73 patients with T2DM who underwent laparoscopic RYGB (LRYGB) to treat morbid obesity. In the group of 73 obese patients (mean BMI = 42.3), there were 41 females and 32 males. Regression of T2DM was observed in 51 patients (69.8%) while hospitalized. In addition, 14 patients' (19.1%) glycemia and HBA1c stabilized within 12 weeks after surgery (total regression rate of 88.9%). The ultimate evaluation of this method of treating T2DM is still lacking and requires several years of meticulous clinical studies. Despite that, considering the high cost of life-long conservative therapy of T2DM and its complications and the severe impact T2DM has on quality of life, surgical metabolic intervention may become the most reasonable solution in many cases.
    Surgical Endoscopy 02/2012; 26(8):2202-7. DOI:10.1007/s00464-012-2160-4 · 3.26 Impact Factor
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