Article Number: 1007- 1989(2010)04- 0370- 04・Thesis・Chinese Journal of Endoscopy Vol. 16, No. 4 2010
Laparoscopic Roux-en-Y gastrointestinal bypass for type 2 diabetes mellitus Dongbo Lian, Department of Hepatobiliary Surgery, Beijing Saitan Hospital, Capital Medical University
Lian Dongbo, Amin Buhe, Zhu Bin, Gong Ke, Li Kai, Wang Tongsheng, Zhang Dongdong, Zhang Nengwei#.
(Center for Laparoscopic Surgery, Ninth Clinical College of Peking University, Beijing Saitan Hospital, Beijing 100038, China)
[Abstract] Objective To review the data of laparoscopic Roux-en-Y gastrointestinal bypass for type 2 diabetes mellitus in our hospital and analyze the efficacy. Methods Preoperatively, the diagnosis of type 2 diabetes mellitus was determined, all examinations were improved, contraindications to surgery were excluded, and laparoscopic Roux-en-Y gastrointestinal bypass was performed under general anesthesia. Results The patient recovered well after surgery without complications, did not need any glucose-lowering drugs after surgery, had good glycemic control, the results of glucose tolerance test turned out to be normal, and no malnutrition or anemia occurred. Conclusion This patient was cured of type 2 diabetes mellitus after laparoscopic Roux-en-Y gastrointestinal bypass treatment.
[Keywords] Laparoscopy; Roux-en-Y gastrointestinal bypass; type 2 diabetes mellitus
Laparoscopic Roux-en-Y Gastric Bypass
For the Treatment of Type 2 Diabetes Mellitus
LIAN Dong-bo, AMIN Bu-he, ZHU Bin, GONG Ke, LI Kai, WANG Tong-sheng, ZHANG Dong-dong, ZHANG Neng-wei#
(Department of Laparoscopic Surgery, Beijing Shijitan Hospital, Peking University Ninth Hospital, Beijing 100038, P.R. China)
[Abstract] Objective To review the first case of curing type 2 diabetes mellitus using laparoscopic Roux-en-Y gastric bypass and to analyze the clinical outcome. Method The patient was diagnosed as type 2 diabetes mellitus definitely, general examination was performed, and underwent laparoscopic Roux-en-Y gastric bypass. The post-operative recovery, serum glucose, Homa-IR, OGTT, nutrition status and complication were analyzed. recovery was fast and no complication occurred, the post-operative level of serum glucose was normal without any antidiabetic medicine, the result of Conclusion The patient with type 2 diabetes mellitus was cured by laparoscopic The patient with type 2 diabetes mellitus was cured by laparoscopic Roux-en-Y gastric bypass.
[Keywords】Laparoscopy; Roux-en-Y Gastric Bypass; Type 2 Diabetes Mellitus
According to the latest epidemiological findings, the prevalence of diabetes mellitus in adults over 20 years of age in China has exceeded 10%, reaching 11.66%, including 13.31% in men and 10.59% in women [1], and diabetes mellitus has increasingly become a major problem endangering human health. Among diabetic patients, type 2 diabetes accounts for the majority. The current treatment of diabetes mainly includes diet, exercise, oral hypoglycemic drugs and the use of insulin, but it rarely restores patients’ blood glucose to normal levels. In recent years, foreign countries have found that Roux-en-Y gastrointestinal bypass can lead to better glycemic control in type 2 diabetic patients by analyzing the data of morbidly obese patients who underwent bariatric surgery [2-5]. The experience of the first case of laparoscopic Roux-en-Y gastrointestinal bypass for type 2 diabetes performed in our hospital is reported below.
1. data and methods
1.1. clinical data: the patient was a male, aged 49 years. He had been clinically diagnosed with type 2 diabetes mellitus for 9 years and was taking oral hypoglycemic drugs with poor results. He had undergone “coronary artery bypass grafting” in 2008 due to “atherosclerotic heart disease”. He volunteered to undergo the procedure and received long-term follow-up for more than 2 years. The body mass index (BMI) was 27.31 kg/m2, total cholesterol 6.04 mmol/L, triglycerides 1.95 mmol/L, and glycosylated hemoglobin 11%, and the patient had no evidence of anterior pituitary, thyroid, or adrenal cortical dysfunction. Blood glucose was controlled with conventional insulin (34 U/day) before surgery. The insulin pump was used to control blood glucose in the early postoperative period, and any glucose-lowering drugs were discontinued as soon as food was started.
1.2. Observation indexes: blood glucose, glycosylated hemoglobin, BMI, oral glucose tolerance test, insulin resistance index [6] (Homa-IR = fasting blood glucose × fasting insulin/ 22.5), changes in diabetic complications were observed before surgery and 3 months after surgery, and upper gastrointestinal imaging was performed at 30 days and 3 months after surgery.
2. Results
2.1. blood glucose changes: see Table 1. it can be seen that the fasting blood glucose level decreased from 17.38 mmol/L before surgery to 6.68 mmol/L at 3 months after surgery, while glycosylated hemoglobin decreased from 11% before surgery to 6.6% after surgery (8.8% at 1 month after surgery), showing that blood glucose could be maintained at a stable low level after surgery.
Table 1. Pre-operative and post-operative changes in blood glucose and insulin resistance
Fasting blood glucose (mmol/L)
Fasting insulin (μU/ml)
Insulin resistance
(Homa-IR)
HbA1c
(%)
Preoperative
17.38
5.9
4.56
11
3 months postoperatively
6.68
4.1
1.22
6.6
2.2. change in insulin resistance: see Table 1. the insulin resistance index (Homa-IR) decreased from 4.56 preoperatively to 1.22 at 3 months postoperatively.
2.3. altered glucose tolerance test.
The results of the preoperative glucose tolerance test showed that the patient’s peak insulin secretion was delayed until 2 hours after the meal. In contrast, the patient’s blood glucose level continued to rise after oral glucose powder until it reached a peak of 26.45 mmol/L at 2 hours, and began to decrease after 2 hours.
The results of glucose tolerance at 3 months after surgery showed that the peak of insulin secretion occurred half an hour after meal, and the insulin level was significantly higher compared with that before surgery, correspondingly, the postprandial blood glucose started to decrease from half an hour after meal, and the blood glucose decreased to the normal range 2 hours after meal.
2.4. Changes in preoperative and postoperative monitoring indexes: see Table 2. The results showed that there was no significant difference in the nutritional indexes of the patients, while cholesterol, triglyceride and LDL-C levels were reduced and HDL-C levels were increased.
Table 2. changes in preoperative and postoperative monitoring indicators
Body weight
(kg)
BMI
(kg/m2)
Albumin
(g/L)
Cholesterol
(mmol/L)
Triglycerides
(mmol/L)
HDL-C
(mmol/L)
LDL-C
(mmol/L)
Serum iron
(mmol/L)
Preoperative
78
27.3
44.6
6.04
1.95
0.96
3.88
15.9
3 months postoperatively
64
22.4
44.6
4.48
1.01
1.12
2.79
19.8
2.5. Postoperative recovery: The patient was discharged from bed on the first postoperative day, and the gastric tube was removed on the second postoperative day, and the patient started to eat liquid food on the third postoperative day. The patient was also discharged on the 10th postoperative day on a semi-liquid diet and resumed normal diet (less frequent meals) on the 30th postoperative day with adequate protein (60~80g per day) and essential vitamins and trace elements. The upper gastrointestinal imaging performed 30 days after surgery all showed a clear digestive tract with good mucosal visualization and no obvious obstruction or reflux, and the upper gastrointestinal imaging performed 3 months after surgery showed mild esophageal reflux.
2.6. Surgical complications: No surgery-related complications occurred.
2.7. Follow-up and long-term complications: The patient was closely followed up and had a feeling of obstruction after eating too fast about 20 days after surgery, which was relieved by giving dietary modification. At 3 months postoperatively, there was mild acid reflux, which was relieved by the administration of mucosal protectants and gastric motility drugs. At the time of publication, the patient did not show any significant malnutrition or anemia at the 3-month postoperative follow-up.
3. Discussion
In recent years, foreign countries have found through analysis of morbidly obese patients who underwent bariatric surgery that procedures such as Roux-en-Y gastric bypass (GBP) have not only achieved satisfactory efficacy in the treatment of morbid obesity, but also have an unexpected effect on the control of type 2 diabetes mellitus, with a remission rate of diabetes mellitus of 80-100% [1- 5].
As for the reasons for the decrease in blood glucose in patients undergoing Roux-en-Y gastric bypass, there is evidence that there is no direct relationship with weight loss. The return to normal blood glucose, blood insulin, and glycosylated hemoglobin occurs before weight loss, which is a long and slow process that takes several years [1]. a case detailed by Pories in another report [7] is typical: the need for medications such as insulin ceased on postoperative day 6 and blood glucose remained normal throughout thereafter. On the other hand, if reduced food intake can explain the control of diabetes after GBP, then various gastric reduction plasty procedures (VBG, AGB, etc.), which rarely improve hyperglycemia, should be more convenient and effective. Therefore, the remission or cure of diabetes after GBP in obese patients with T2DM is not secondary to the treatment of obesity, but a primary, specific effect. The main consideration at present is related to changes in gastrointestinal hormones after surgery. The main principle of the foregut hypothesis is that the food does not pass through the duodenum and upper jejunum, which leads to a decrease in the secretion of certain anti-incretin, thus relieving the resistance to insulin and the blood glucose return to normal. The hindgut hypothesis, on the other hand, explains that under-digested food reaches the terminal ileum too quickly, leading to an increase in the secretion of certain intestinal hypoglycemins (incretin) and a decrease in blood sugar.
Since reduced food intake and weight loss are not the underlying cause of curing diabetes, GBP should also be able to control blood glucose in non-obese patients with type 2 diabetes.Animal experiments reported by Rubino [8] first demonstrated that diversion surgery also provides good control in non-obese type 2 diabetes. Li Lei [9] et al. reviewed patients who underwent Billroth II-style gastrointestinal reconstruction for gastric cancer and found that glycemia was also well controlled, and the mean BMI of these patients was 24.7 kg/m2. In China, Zhang Xinguo [10,11] has performed open GBP surgery to treat type 2 diabetes, and the results showed that both for obese and non-obese patients, GBP can showed more satisfactory glycemic control in both obese and non-obese patients. All these data show that GBP can be used to treat type 2 diabetes alone.
In foreign countries, this type of procedure is currently done under full laparoscopy, which is not yet performed in China. However, laparoscopy has indisputable advantages over open surgery, such as less trauma and faster recovery, and will certainly become the trend of this type of surgery. In this case, the patient got out of bed on the first postoperative day and had exhaustion on the second postoperative day, which fully demonstrated the minimally invasive advantages of laparoscopic surgery.
The patient recovered smoothly after surgery and no surgical complications occurred. All the preoperative blood glucose levels were high, and at 3 months postoperatively, blood glucose could be maintained at a better level without any drugs, and glycosylated hemoglobin steadily decreased, indicating that laparoscopic Roux-en-Y gastric bypass is effective in the treatment of type 2 diabetes. Meanwhile, we found that the results of the postoperative glucose tolerance test showed that the patient’s insulin secretion level and insulin peak reached normal levels, and the arrival time of peak was significantly advanced from 2 hours after meal before surgery to half an hour after meal, suggesting that the patient’s pancreatic islet function improved significantly after surgery. At the same time, the patient’s insulin resistance level also decreased significantly, which gave us a more optimistic expectation for the long-term glycemic control of this patient.
Laparoscopic Roux-en-Y gastric bypass offers a new approach to the treatment of diabetes, but as a new technique, there are still more issues to be addressed. First, research on the mechanism of treating diabetes should be strengthened so that it can guide the treatment theoretically; second, the current procedure lacks uniform specifications, and the specific details of the procedure, including the size of the preserved gastric bursa, the Roux arm and the length of the common channel, are still not uniform. In terms of treatment effect and reduction of long-term complications, it is still necessary to actively educate patients, increase their compliance, and adjust their dietary habits appropriately to ensure satisfactory glycemic control while avoiding malnutrition complications. It is believed that as research continues to progress, Roux-en-Y gastric bypass for type 2 diabetes, a technique derived from evidence-based medicine, will have a broader future.