I. Expert consensus on metabolic surgery for diabetes.
With the continuous development of society and changes in people’s lifestyles, diabetes has become an “epidemic”, spreading all over the world. With the continuous development of society and the change of people’s lifestyle, diabetes has become an “epidemic”, spreading all over the world. According to a survey conducted by the Chinese Medical Association’s Diabetes Division “China Diabetes and Metabolic Syndrome Research Group” from 2007 to 2008, the prevalence of diabetes among men and women over 20 years of age in China reached 10.6% and 8.8% respectively, with an overall prevalence of 9.7%, and the prevalence of pre-diabetes was as high as 15.5%. The prevalence of pre-diabetes is as high as 15.5%, which means that the total number of people with diabetes in China has reached 92.4 million, and the number of people with pre-diabetes has reached 148 million. The treatment of diabetes has become an urgent concern for us.
The traditional treatment of diabetes mellitus mainly adopts internal therapy, including diet control, strengthening exercise, oral hypoglycemic drugs and insulin injection, etc. However, there is no method that can control the disease and its complications more satisfactorily, and lifelong medication and insulin injection make the long-term compliance of patients poor. In recent years, foreign countries have analyzed the effect of obesity surgery and found that after obese patients underwent gastrointestinal surgery, not only did they lose weight significantly, but their complications of type 2 diabetes mellitus (T2DM) were relieved unexpectedly, and similar reports have been made in China.
The improvement and remission of diabetes by surgical treatment originated from the discovery of Pories et al. When Pories performed gastric bypass surgery (GBP) to treat morbid obesity, he found by chance that patients with T2 DM combined with significant postoperative weight loss also had a rapid return to normal blood glucose, and some patients even did not need glucose-lowering drugs for maintenance. Subsequently, in a prospective controlled study, Ferchak et al. found that the number of patients with T2 DM in combination with obesity who underwent UBP for obesity who did not require glucose lowering and maintained normal blood glucose over time was significantly higher than in the non-operative group, and the incidence of diabetes-related complications and mortality were greatly reduced – Aiterburn et al. also found that patients with postoperative systolic blood pressure In 2008, an Australian study showed that surgical treatment of obese T2 DM patients significantly improved the remission rate of T2DM compared to lifestyle 10. In addition, a study on the health economics of surgical treatment of obesity found that surgical treatment can achieve a better balance between benefits and costs, thus reducing the economic burden for the obese diabetic patients themselves and society.
Among the many bariatric surgical procedures, GBY has been studied earlier and more frequently, with the best results in patients with T2DM with obesity.1 A prospective cohort study from Hong Kong between July 2002 and December 2007 applied laparoscopic adjustable gastric banding (LAGB, 57 cases), laparoscopic gastric sleeve, and laparoscopic gastric banding (LAGB). ), laparoscopic sleevre gastrectomy (LSG , 30 cases) and laparoscopic gastric bypass (LGB , 7 cases) for the treatment of morbid obesity, the mean weight loss rate of patients at 2 years after surgery was 34% in the LAGB group , The average weight loss rate at 2 years after surgery was 34% in the LAGB group and 51% in the LSG group and 61% in the LGB group. Obesity-related conditions, including metabolic syndrome, T2 DM, hypertension, and sleep apnea syndrome, were significantly improved. lee et al. studied 1375 patients who underwent bariatric surgery from 1997 to 2006, including laparoscopic `vertical banding gastroplastv Among them, 166 had impaired fasting glucose regulation (IFG) and 247 had T2DM; 1 year after surgery, 78.5% of patients with T2 DM and 94.7% of patients with IFG had normalized fasting glucose, and 81.5% of patients with T2 DM had normalized glycated hemoglobin (HbAl c) levels. Peluso et al. retrospectively studied 400 patients who had undergone GBY and statistically analyzed the comorbidities associated with obesity. 12.8 (0.3-30. 6) months of follow-up, 80% to 100% of patients with comorbid diabetes were in remission or improved, and concluded that patients who underwent GBP had a significant improvement in quality of survival after surgery compared to preoperative. 2010 American In 2010, the Diabetes Surgery Summit (DSS) published a consensus that GBP is an ideal treatment for obese diabetic patients with a body mass index (BMI) ≥ 30 kg/m2 who have poor glycemic control. In terms of outcomes alone, Rubino believes that Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are better for T2DM than for obesity, thus calling them The term “metabolic surgery” or “diabetic surgery” seems to be more appropriate and has been clearly stated in the recent Diabetic Surgery Summit that LAGB and LSG are not as effective as RYGB in treating diabetes. The efficacy of obese T2DM decreases as the disease worsens, so in principle, early surgery and good preoperative diabetes control are advocated. Recently, the International Diabetes Federation (IDF) issued a bean field statement to officially recognize metabolic surgery as a treatment for T2DM.
Therefore, metabolic surgery has become one of the options for the treatment of T2 DM, but there are certain risks associated with metabolic surgery, so how to make the surgical treatment more standardized and benefit more patients with T2 DM on the basis of standardized treatment is a current issue worthy of attention.
Second, the indications for metabolic surgery for diabetes mellitus.
1, BMI ≥ 35 kg/m2 with or without comorbidities in the T2 DM subpopulation, can be considered for weight loss/gastrointestinal metabolic surgery.
2. In Asian population with BMI 30~35 kg/m2 and T2 DM, weight loss/gastrointestinal metabolic surgery should be one of the treatment options when it is difficult to control blood glucose or comorbidities by lifestyle and medication, especially when there are cardiovascular risk factors.
3.Asian population with BMI 28.0~29.9 kg/m2 with combined T2 DM and centripetal obesity (waist circumference >85 cm for women and >90 cm for men) and at least 2 additional criteria for metabolic syndrome: high triglycerides, low HDL cholesterol level, and high blood pressure. Weight reduction/gastrointestinal metabolic surgery for the above patients can also be considered as one of the treatment options.
4. For adolescents with BMI ≥ 40 kg/m2 or ≥ 35 kg/m2 with severe comorbidities, and who are ≥ 15 years old, skeletally mature, and in Tanner developmental class 4 or 5, LAGB or RYGB may be considered as one of the treatment options with the patient’s informed consent.
5. For T2DM patients with BMI 25.0~27.9 kg/m2. Surgery should be performed with the patient’s informed consent and strictly according to the study protocol. However, the nature of these procedures should be considered purely as part of a pilot study approved in advance by the ethics committee only, and should not be widely promoted.
6. Patients with T2 DM who are < 60 years of age or in good general health with low surgical risk.
III. Contraindications to metabolic surgery for the treatment of diabetes mellitus.
1, Patients with drug or alcohol abuse addiction or mental illness that is difficult to control and patients who lack the ability to understand the risks, benefits, and expected consequences of metabolic surgery.
2. Patients with a clear diagnosis of type 1 diabetes mellitus.
3.Patients with T2 DM whose pancreatic islet beta cell function has been largely lost.
4.Patients with combined abnormal coagulation disorders and cardiopulmonary function that cannot tolerate surgery.
5.Diabetic patients with BMI < 28 kg/m2 and whose blood glucose can be satisfactorily controlled with medication and insulin.
6.Gestational diabetes and other special types of diabetes are temporarily excluded from the scope of surgical treatment.
IV. Clinical risks of metabolic surgery.
(A) Risk of surgical death
The data from 272 bariatric surgery treatment centers certified by the American Society for Bariatric Surgery showed that the 30 d and 90 d postoperative mortality rates of GBP were 0.29% and 0.35%, respectively] Buchwald et al. conducted a meta-analysis of the total mortality rate of bariatric surgery, the 30 d postoperative mortality rate of LAGS was 0.1%, and the 30 d postoperative mortality rate of GBP was 0.5%. Therefore, although the risk of death from bariatric surgery is lower than the risk of general surgery, there is still a certain rate of morbidity and mortality.
(ii) Recent postoperative complications
A domestic project followed up 172 simple obese patients after LAGB found that early postoperative complications included 4 cases (2.3%) of incisional infection at the buried pump; distant complications included 2 cases (1.2%) of late buried pump site infection, 2 cases (1.2%), subcutaneous turning of the adjustment pump, 1 case (0.6%) of non-healing ulcer due to significant postoperative weight loss resulting in exposure of the adjustment pump, and 7 cases (4.1%) of non-healing ulcer. 4.1%) had dilated gastric bursae, 1 case (0.6%) had chronic intestinal obstruction symptoms 1 year after surgery, and 1 patient (0.6%) had mild alopecia. Therefore, immediate and long-term postoperative complications are problems that cannot be ignored in metabolic surgery for T2DM.
1, intestinal obstruction (intestinal obstruction ): the risk of intestinal obstruction after open GBP is 1.3%-4.0%, while the risk of occurrence after laparoscopic surgery is as high as 1.8%-7.3%, in which, after LAGB, the incidence of small bowel obstruction secondary to intra-abdominal disease is 2.6%-5.0%, and this complication often occurs in the distant postoperative period . The main causes of intestinal obstruction after gastrointestinal bypass surgery are intestinal adhesions, intra-abdominal defects, bleeding gastrointestinal stones, embedded abdominal temples or intussusception.
2. Anastomotic leak: Anastomotic leak is the most common complication of GBP. The incidence is 1.5% to 5.5%, with leaks originating from the anastomosis and around the L1-shaped nail being the most dangerous. Patients will present with various manifestations of tachycardia and sepsis, which can occur immediately after surgery or after the seventh or tenth day of surgery.
Pulmonary embolism: Pulmonary embolism is one of the acute complications of bariatric surgery that is second only to anastomotic leak in severity, with an incidence of 1%-2%, but its mortality rate is as high as 20%-30%, and its incidence is greatly increased in patients who are frequently bedridden before and after surgery.
4, deep vein thrombosis: for moderately obese patients, especially those who lack exercise before surgery, deep vein thrombosis is likely to occur after any bariatric surgery.
5, portal vein injury: Bariatric surgery complications of portal vein injury are rare. However, once it occurs, the risk of death is greatly increased. Foreign literature reports 3 cases of portal vein injury after bariatric surgery, and the patients still died after liver transplantation.
6, respiratory complications: Bariatric surgery is most often complicated by respiratory disease, which may be related to the way the patient is managed in the community after surgery. A few clinical centers have reported that the application of continuous positive pressure ventilation (CPAP) after bariatric surgery can reduce the risk of postoperative pulmonary atelectasis and pneumonia.
(iii) Long-term postoperative complications
1, elimination than the system disease: after bariatric surgery, due to rapid weight loss, resulting in gallstone formation, so the incidence of postoperative combined gallstone disease is 3%-30%, after the line of GBP can be complicated by dumping syndrome According to the survey, 70% of the line of GBP patients have varying degrees of gastroparesis, mainly manifested as postprandial abdominal distension, abdominal pain.
2, malnutrition: malnutrition is a possible complication after any kind of bariatric surgery. Postoperative guidance and lifelong follow-up should be provided by a dietitian (1} Iron deficiency anemia and folic acid deficiency: 1 prospective study on GBP found that 36% of women and 6% of men had postoperative anemia, 50% of women and 20% of men had a decrease in body iron, and 18% of patients had reduced folic acid reserves. Retrospective studies have also found similar results for iron and folic acid deficiency, with lower levels in menstruating women. (2) Vitamin B12 (VitB12) deficiency: The highest incidence of postoperative VitB12 deficiency has been reported at 70%. Early thought that VitBl2 deficiency after GBP was due to a decrease in endogenous factors, it is now thought to be due to reduced gastric acidity and reduced release of VitB12 from the diet. A meta-analysis of 9413 patients with GBP showed that the incidence of postoperative malnutrition and anemia was 6%, and the 10-year postoperative mortality rate was only 0.98%. Malnutrition. It may be due to a reduction in nutritional intake. The patient may not be able to eat foods rich in certain nutrients after surgery because of intolerance. (3) Calcium and vitamin D (VitD) deficiency: Calcium and VitD deficiency is mainly due to malabsorption of calcium and VitD in the open segment of the intestinal bypass, which in turn leads to malabsorption of calcium. With the relative lack of calcium, parathyroid hormone (PTH) levels increase, which in turn leads to the release of calcium from the bone, increasing the risk of osteoporosis.
V. Management of metabolic surgery.
1. Preoperative screening and evaluation: Internal medicine doctors with expertise in endocrinology screen diabetic patients with poor results of medical treatment, and preoperative evaluation of patients with indications for metabolic surgery, and recommend these patients to comprehensive medical units with metabolic surgery qualifications for metabolic surgery.
2, metabolic surgery treatment: the surgical treatment of T2DM may involve several different clinical disciplines due to the special condition of the patient, the treatment process and perioperative management, so it is recommended that the surgery should be carried out in a comprehensive medical unit at level 2 or above [the operator should be a gastrointestinal surgeon with the title of intermediate or above, who has been practicing in general surgery for a long time, and who understands the treatment principles and operational guidelines of various surgical procedures. Only after systematic instruction and training can the operation be performed.
3.Post-operative follow-up: After surgery, patients need to be followed up for life by a team of bariatric surgeons and Nei Liyi doctors and nutritionists who are familiar with this field. The discomfort measures are drinking sufficient amount of fluids, eating sufficient protein, and supplementing with essential vitamins and minerals. The methods are as follows.
(1) low-sugar, low-fat diet; (2) avoid overfeeding; (3) eat slowly, 20-30 min per meal; (4) chew slowly and avoid swallowing too hard or large pieces of food; (5) eat protein-rich foods first and avoid high-calorie foods; (6) depending on the surgical procedure, some require daily essential vitamin supplementation and mineral supplementation according to instructions; and (7) ensure daily (7) Ensure adequate daily intake of fluids. Avoid rabbit carbonated beverages I For women of childbearing age undergoing weight loss surgery, pregnancy should be avoided within 1 year after surgery if possible, and if pregnant, nutritional status should be monitored to prevent postoperative malnutrition.
In addition, large-scale clinical studies are needed to evaluate and control various medical and surgical therapies and long-term follow-up to help us develop more rational protocols through evidence-based medicine, so that medical and surgical treatments can better synergize and work together to treat diabetes rationally and effectively.
VI.Conclusion.
It is still believed that medical therapy is the foundation of diabetes treatment and is used throughout the treatment of diabetes; on this basis, an active and effective division of labor between medical and surgical practitioners is needed to work together to minimize the pain and burden of diabetes to patients.