Type 2 diabetes is a common health problem, with more than 150 million people suffering from type 2 diabetes worldwide, and the current prevalence of diabetes in adults in China is about 9.7%, with a total of about 92.4 million people, and the number of people with prediabetes has reached 148 million, of which T2DM accounts for 90%. Although there are reports in recent years proving that strict control of hyperglycemia can control the complications of type 2 diabetes, current treatment rarely allows patients to completely restore their blood glucose to normal. Surgical procedures can not only lead to lasting and significant weight loss in patients, but also improve or cure their co-morbidities, especially type 2 diabetes. 2007-2008 Chinese Medical Association Sugar diabetes has become the third major non-communicable disease after cardiovascular diseases and tumors, and is a worldwide public health problem that seriously threatens human health. In 2009, the American Diabetes Association (ADA), the world’s leading authority on diabetes treatment, included gastric bypass surgery in the Diabetes Prevention and Control Guidelines, identifying it as a routine treatment for diabetes. In September of the same year, the European Diabetes Association considered diabetes to be a curable gastrointestinal disease.
1. Why can surgery cure diabetes?
The latest theory describes type 2 diabetes as a multi-phase disorder. The main mechanisms of gastrointestinal surgery to treat diabetes may be.
(1) Reduced food intake and absorption, thus reducing energy intake and glucose metabolic load.
(2) The effect of Ghrelin.
Ghrelin-like growth hormone is mainly secreted by the base of the stomach and is the gastrointestinal hormone in charge of appetite control.
(3) The effect of duodenal isolation.
The duodenum is the body’s primary control of oral glucose metabolism, and recent studies have shown that the development of diabetes is related to problems in the duodenum’s blood glucose regulation mechanism. Most patients have abnormal elevations of glucagon and VIP, and isolation of food into the duodenum after surgery can reduce abnormal intestinal hormonal responses, thereby improving the condition of diabetes.
(4) Remote intestinal stimulation and weight loss surgery can make food enter the remote intestinal tract rapidly, causing many intestinal hormones, such as glucagon-like peptide 1 (GLP-1) and casein peptide (PYY) to increase rapidly, which is a new drug opportunity for the treatment of diabetes.
2.What kind of diabetic patients are suitable to receive surgery?
Referring to the 2010 China Diabetes Surgery Summit and Consensus Conference and the opinions of the Chinese Diabetes Surgery Treatment Expert Group, the current indications for surgery in China include
(1) Patients aged ≤ 65 years.
(2) Patients with T2DM of ≤15 years.
(3) The patient’s islet reserve function is above 1/2 of the lower limit of normal, and C-peptide is ≥ 1/2 of the lower limit of normal.
(4) The patient’s waist circumference diabetes mellitus is very closely related to insulin resistance. The insulin resistance and intra-abdominal fat accumulation are inextricably linked, therefore the patient’s waist circumference >90cm in men and >80cm in women is also one of the options for surgical treatment.
(5) The presence or absence of comorbidities in diabetes is likely to cause large and small vessel lesions. (5) The presence of comorbidities Diabetes is prone to large and small vessel lesions. Special attention should be paid to visual changes, cardiac and renal function, and further investigations should be arranged if there are signs of vascular disease. If the patient is blind, has significant kidney damage or has a history of myocardial infarction or stroke, any surgical treatment is not recommended.
(6) At the same time, the patient should be free from serious mental disorders and intellectual disabilities; the patient should fully understand the surgical treatment for diabetes, understand and be willing to take the risk of potential complications of the surgery, understand the importance of postoperative diet and lifestyle changes and be willing to bear them; the patient should be able to actively cooperate with postoperative follow-up, etc. are also factors to be considered in the selection of surgery.
3.What are the main surgical procedures for diabetic patients?
With the gradual improvement of the current laparoscopic technology, the mainstream surgery is mainly divided into.
(1) laparoscopic sleeve gastrectomy: the resected stomach cannot be recovered. (1) Laparoscopic sleeve gastrectomy: the resected stomach cannot be recovered. For patients with extreme obesity and high-risk patients with other serious obesity complications, this surgery can be performed first, and the expectation of the weight loss effect will determine whether the second stage surgery is needed. The second-stage surgery is usually performed 6 to 18 months after the first-stage surgery.
(2) Laparoscopic Roux-en-Y gastrojejunostomy.
4.What are the risks after surgery for diabetic patients?
Post-surgical surgery substantially reduces the morbidity and mortality caused by diabetic comorbidities, with patients <65 years of age showing efficacy after 6 months and those >65 years of age showing efficacy after 11 months. Clinical observations have confirmed that the mortality rate of RYGBP surgery is 0% to 1.5%, and the main complications are anastomotic leak, pulmonary embolism, and intestinal obstruction, with an incidence of 0.6% to 6%. The overall efficiency of gastric diversion surgery for type 2 diabetes is 95%, and the remission rate is 83%. Moreover, the efficiency of the surgery is 100% for type 2 diabetes with a disease duration of less than five years, and about 70% for those with a disease duration of more than 10 years. Depending on the insulin resistance and islet cell function of each individual, the onset of effect can be as fast as 3 weeks and as slow as one year. Combined with our experience, the blood sugar of cases in complete remission after surgery does not need any glucose-lowering drugs and can be maintained in the normal range, and insulin treatment is still needed in a few cases, but the dosage is only about a quarter of that before surgery.
5.Is surgery suitable for every diabetic patient?
Surgery for diabetes has so many advantages, but is it without any risk? Some complications of laparoscopic surgery, such as bleeding, anastomotic leak, anastomotic stricture, intestinal adhesion, intestinal obstruction, etc., may occur, but the proportion is still relatively low, less than 2% as reported in the literature, and we have not had any complications so far, but objectively these complications may still occur. In addition, the efficiency of surgery is 95% and the complete remission rate is more than 83%, which means that not everyone can get a good result after surgery. Therefore, we should still look at the issue of diabetes surgery objectively and rationally. It is necessary for the professional treating physicians to combine the indications for surgery, conduct strict preoperative screening, and give surgery to suitable patients so as to achieve maximum results and allow both patients and physicians to smile about the future.