1. Why “gastric diversion” surgery can cure type 2 diabetes
There are two major causes of type 2 diabetes. As the saying goes, “the cure must be the right cure”, so before we understand “gastric diversion” surgery, we must first understand what are the causes of type 2 diabetes. For example, if we eat a meal, 30 insulins are enough for the average person, but 80 insulins are not enough for patients with insulin resistance, so the same amount of insulin is secreted, and the role of insulin resistance is not enough for patients with insulin resistance. The second cause of the disease is islet failure. Because the pancreatic islets are overloaded with insulin for a long time, the workload is too great and the pancreatic islet cells die too much, the function of the pancreatic islets then fails, and diabetes occurs.
Insulin resistance and islet failure are the main causes of type 2 diabetes, and the unique feature of the “gastric diversion” procedure is that the physiological flow of food in the stomach is surgically altered. When a patient is treated for diabetes with gastric diversion, on the one hand, food from the upper GI tract is diverted away from the distal stomach, duodenum and upper jejunum.
When K cells are stimulated by food, they secrete a large amount of cytokines called insulin resistance factors, which reduce the effect of insulin.
On the other hand, after surgery, the incompletely digested food can enter the middle and lower digestive tract earlier, stimulating a large number of substance L cells inside the mucosa of the middle and lower digestive tract, and L cells, after food stimulation, will secrete some cytokines such as GRP-1 and PYY, which have a common effect: first, directly lowering blood sugar; second, reducing the rate of islet cell apoptosis; third, stimulating islet cell proliferation. stimulate islet cell proliferation. In other words, the islet cells can change from one to two, two to four, and proliferate in number. These cytokines can also protect islet cells from glucotoxicity and some other inflammatory hazards.
2. What is the current status of “gastric diversion” surgery?
Many patients may ask, “Since this is a surgical procedure, is there a great risk of surgery? The whole procedure takes only about one hour, and it is suitable for most type 2 diabetic patients because of its small trauma, quick recovery and low risk.
First, the “gastric diversion” procedure does not require the removal of any body parts. The whole procedure is divided into two steps: one is to separate the stomach cavity, and the other is to reconstruct the digestive tract. The procedure can be completed in 40-60 minutes. The average length of stay after surgery is about 10-14 days. Patients usually have a significant decrease in blood sugar after surgery, and most of them have normalized their blood sugar after discharge, and their diabetic complications gradually disappear, and they basically recover in half a month. For some patients, it takes 4 months for the blood sugar to gradually return to normal and type 2 diabetes to be cured eventually. The recovery time of patients mainly depends on the recovery of individual pancreatic islet function, and generally the recovery period will not exceed 1 year.
Secondly, the eating requirement of “gastric diversion” surgery is the same as that of general gastrointestinal surgery, which is the rule of “3, 6, 9”. That is, no food for the first 3 days after the operation, liquid food for 3-6 days, semi-liquid food for 6-9 days after the operation, and normal food after 9 days. This procedure is low risk, and so far, no serious complications have been found, and no malnutrition has been found.
3.What are the unique features of “gastric diversion” surgery for diabetes?
Compared with the traditional treatment of diabetes, “gastric diversion” surgery has six unique advantages.
First, it can treat type 2 diabetes at once and stabilize blood sugar for life;
Second, normal diet and free life can be restored;
Third, the complications of diabetes (hyperlipidemia, diabetic foot, etc.) can be improved and cured;
Fourth, obese patients can lose weight and thin patients can gain weight;
Fifth, the post-operative recovery is fast and there are few complications;
Sixth, it eliminates the expensive medical expenses and reduces the economic burden of diabetic patients.
According to the data, the procedure has been clinically applied internationally for nearly 10 years, and no long-term complications have been found in the postoperative patients. On the contrary, in addition to the normalization of blood glucose after the operation and the elimination of the need to take hypoglycemic drugs, a series of complications accompanying diabetic patients have also been well recovered. For example, retinopathy, diabetic dermatitis, diabetic foot, and renal dysfunction have gradually healed. At present, the majority of sugar patients who have received “gastric diversion” surgery have said goodbye to diabetes, and some of them are in a good recovery period.
4.The rigorousness of “gastric diversion” surgery
Many patients may have doubts that “gastric diversion” surgery can be done for every diabetic patient, but it is not. Patients must undergo strict medical tests and be eligible for treatment.
So, which diabetic patients are suitable for “gastric diversion” surgery, such as.
1. The patient meets the diagnostic criteria for type 2 diabetes;
2. The pancreatic islet function is in the compensatory phase (plasma insulin level > 1/3 of normal low value);
3. The history of diabetes is less than 15 years and the age is less than 65 years. Only patients who meet the above requirements can undergo this procedure.
On the contrary, patients are not suitable for gastric diversion surgery if the examination falls under any of the following conditions.
1.Patients with advanced diabetes mellitus and pancreatic islet failure;
2.Serious organic diseases that cannot tolerate the surgery;
3, gastrointestinal tract dysfunction, moderate to severe diabetic gastroparesis;
4, diabetic history greater than 15 years or age greater than 70 years old, suffering from serious complications; In addition, autoimmune diabetic patients are considered as appropriate.
5, gastric diversion surgery can treat type 2 diabetic obesity
When most patients accept the gastric diversion surgery this kind of popular weight reduction surgery, they are surprised to find that in the successful restoration of normal body shape, long troubled their own obesity accompanied by the morbidity surprisingly improved. Blood pressure was normalized, hyperglycemia was reduced, 83% of type 2 diabetics were in remission or cured, and some patients no longer needed insulin injections to maintain normal blood glucose levels, while the symptoms of obesity in type 2 diabetes gradually disappeared and their weight reached a normal range. Originally the safest and most effective weight loss surgery available, gastric diversion surgery has now become a powerful adjunct to the health journey of type 2 diabetic patients.
Bariatric surgery not only corrects glucose metabolism disorders in obese patients, but is also effective in metabolic disorders such as dyslipidemia, primary hypertension, and fatty liver. There is sufficient evidence that the high systolic and diastolic blood pressure of patients after bariatric surgery is reduced, and 65% of hypertensive patients are relieved or cured; the dyslipidemia and fatty liver of patients are relieved, and insulin resistance is corrected.
6. Mechanism of diabetes remission after gastrointestinal surgery
Gastrointestinal surgery has similar efficacy for non-obese T2DM and obese T2DM, except that the weight loss effect of surgery is more obvious when used for the latter, suggesting that the improvement of glucose metabolism after surgery cannot be attributed entirely to weight loss. Research on the glucose-lowering mechanism of small intestine bypass surgery not only helps to elucidate the pathophysiology and pathogenesis of diabetes, but also facilitates the development of new glucose-lowering drugs, making it possible to cure diabetes.
7.What is the hypoglycemic effect of gastrointestinal surgery other than weight reduction?
T2DM remits immediately after gastrointestinal surgery, well before the change in body weight. rygb surgery has the same weight reduction effect as simple gastric decongestion, but the former has a more pronounced improvement in glucose metabolism after surgery. In animal experiments, it was observed that glucose tolerance improved even though there was no weight loss after small bowel surgery. After small bowel surgery, a few patients may develop delayed β-cell hyperfunction. The above phenomenon suggests that small bowel diversion surgery can treat T2DM by a mechanism other than weight loss and reduced food intake.
8. Possible glucose-lowering mechanisms of gastrointestinal surgery
The rearrangement of gastrointestinal tract anatomy can antagonize hyperglycemia and diabetes mellitus through a variety of mechanisms other than food reduction and weight loss. However, the exact mechanism of gastrointestinal surgery for T2DM is not yet known. Possible mechanisms of hypoglycemia other than weight loss include.
1, increased stimulation of the distal small intestine by food and increased secretion of peptides such as GLP-1 by L cells;
2. Avoidance of food contact in the proximal small intestine and decreased secretion of unknown glucagon;
3.Decreased secretion of gastric growth promoter;
4.Altered absorption of nutrients in the small intestine and increased insulin sensitivity;
5.Bile acid factor;
6, other unknown intestinal factors. Procedures with more significant glucose-lowering effects, such as RYGB, can activate several of these mechanisms simultaneously to produce a coordinated effect, resulting in significant remission of T2DM. In addition to several known hormones, the intestine is capable of producing more than 100 bioactive peptides whose effects on glucose metabolism remain to be further investigated. The search for bioactive substances that can improve glucose metabolism after gastrointestinal surgery has far-reaching significance for the development of new glucose-lowering drugs.
9.Cautions for surgical treatment of diabetes mellitus
Before surgical treatment of diabetes, you should actively ask your doctor to monitor your blood glucose level, including checking four segments of urine glucose every day or every other day, and checking fasting or two-hour post-meal glucose once a week. Urine glucose and urine ketone bodies should be measured immediately after surgical treatment for diabetes to determine if diabetic ketosis has occurred as a result of surgical stimulation.
Blood glucose, blood gas analysis and blood carbon dioxide binding capacity should be rechecked the morning after surgery to determine the status of diabetic control and whether acidosis has occurred so that treatment can be adjusted in a timely manner. When you need infusion therapy, glucose fluids should be avoided as much as possible. If it is really necessary, it is advisable to use a mixture of 5% glucose and saline, and add a certain amount of insulin to the fluid as appropriate.
There are many tests to be done before and after the surgical treatment of diabetes, some of which require fasting. When you come across a test that requires fasting, don’t forget to ask your doctor to schedule your tests appropriately and to time your insulin injections at high speed to avoid hypoglycemia.
When you resume eating after surgical treatment for diabetes depends on the anesthesia you receive. If you are under local anesthesia, the postoperative fasting time will be short, and if you are under general anesthesia, the fasting time will be long. The surgeon should be alerted to temporarily adjust the treatment for diabetes based on the length of the fast. Diabetic patients should be hospitalized for a longer period of time after the surgical treatment of diabetes. The incision should be observed for a few more days after the incision is grasped and the possibility of infection of the incision should be convinced to be reduced before discharge.
10.Surgery retrospective
The first residual gastric-jejunal anastomosis performed. The unique feature of the gastric diversion procedure is that the normal physiological flow of food is altered and divided into two parts of the digestive tract area according to whether food passes through or not.
(i) Food diversion zone, i.e., most of the stomach, duodenum and proximal jejunum, a blind section of the GI tract, through which no food passes;
(ii) the food transit zone, i.e., the distal jejunum and ileum, where this part of the GI tract receives food in advance.
Gastric diversion surgery can be performed by conventional open method or by laparoscopic method to achieve the same effect and less invasive, generally 30-45 minutes to complete the surgery. At present, the total number of cases of surgery for diabetes in China has reached more than 1000, with complication rates of 1% to 3% and no surgical deaths.