Diabetes is a serious public health problem worldwide, seriously endangering the health of patients and consuming large amounts of social resources, and has been an important direction for medical research. It is currently estimated that there are more than 170 million diabetics worldwide, and this number is still growing. 85 to 90% of them are type 2 diabetes, and 90% of type 2 diabetes is combined with obesity or overweight.
Obesity combined with type 2 diabetes has traditionally been considered a medical condition, and treatment is based on diet modification, exercise, oral hypoglycemic drugs and insulin injections. These methods can be effective in the short term, but long-term weight loss and maintenance of normoglycemia are not effective. Later, the surgical treatment of obesity represented by gastric bypass and various gastric decompression procedures gradually emerged and achieved significant and sustained weight loss, with a total overweight weight loss of up to 61.2%.
The surgeon, who performed gastric bypass bariatric surgery on some obese patients with combined type 2 diabetes, unexpectedly found that they lost weight while their blood sugar returned to normal and no longer required any treatment, and his 14-year follow-up of 146 such patients showed a cure rate of 83% for type 2 diabetes. Following this important discovery, research on the treatment of obesity combined with type 2 diabetes through gastrointestinal surgery has progressed rapidly. A large number of clinical studies have shown that complete remission rates for obesity combined with type 2 diabetes can be as high as 82 to 98% after gastric bypass surgery, with significant improvement in those not in complete remission, and can prevent progression to type 2 diabetes in patients with obesity and impaired glucose tolerance.
At the same time, new insights have been gained into the mechanisms and treatment strategies for the development of obesity and type 2 diabetes. Currently, gastrointestinal surgery has become an important treatment for obesity combined with type 2 diabetes, and its procedures are being improved and selected continuously, and related clinical research and basic research are also progressing in mutual promotion.
Surgical procedures for the treatment of obesity combined with type 2 diabetes include both gastric volume reduction and gastrointestinal diversion. With the maturation of laparoscopic gastrointestinal surgery, almost all of these procedures can be done laparoscopically and without difficulty. This has further reduced the trauma and complications of surgical treatment of obesity and diabetes, making them more acceptable and thus facilitating their use.
The main procedures include
Gastric volume reduction procedures
1. laparoscopic adjustable gastric banding.
3, Vertical banding gastroplasty.
4, There is also a gastric volume reduction method by placing a balloon into the gastric cavity via gastroscopy.
Gastrointestinal diversion procedure
1.Laparoscopic gastric bypass.
2.Laparoscopic mini-gastric bypass.
3.Biliopancreatic diversion.
4.Ileal diversion.
Treatment mechanism.
The pathophysiological mechanism of surgical treatment of obesity and type 2 diabetes is still inconclusive, and there are more hypotheses and controversies. With the development of surgical treatment, related basic and clinical research has gradually advanced, and the level of understanding of such diseases has risen to the level of the neuroendocrine function of the whole gastrointestinal tract.
1, diet reduction, weight loss: reduce gastric volume surgical style can significantly reduce the amount of food and slow down the speed of digestive tract emptying, reduce the absorption of nutrients, significantly reduce body weight and improve morbid obesity. The ectopic deposition of free fatty acid in obesity produces lipotoxicity to non-adipocytes and causes insulin resistance, so the improvement of obesity state is beneficial to eliminate insulin resistance and improve diabetes. However, there are also reports showing that some patients receive bariatric surgery after the blood glucose level in the near future that there is a significant decline, and only in the 12 months after surgery there is a significant improvement, suggesting that the mechanism of surgical treatment is not only weight loss.
2, adipose islet axis: adipocytes have complex molecular biological functions, secrete a variety of adipocyte factors including leptin, lipocalin, acylation-stimulating protein and resistin, participate in regulating glucose and lipid metabolism, and play an important role in energy maintenance, cardiovascular function and internal environment stability, immune response, etc. Therefore, adipocyte factors are closely related to obesity and its complications such as diabetes
3, the digestive tract endocrine function change: the digestive tract is the body’s largest endocrine organs, containing a huge variety and number of endocrine cells, to a variety of external stimuli to make characteristic responses, and there is a chain of mutual promotion or check and balance feedback pathway, forming a large and complex effect, intensity, time phase network, together to maintain the body’s neuroendocrine function balance.
Another hypothesis is that the upper part of the small intestine secretes hormones that inhibit insulin secretion when stimulated by food, while the distal part of the small intestine secretes hormones that promote insulin secretion when stimulated by food. The diet of modern life is very fine, and most of it has been digested and absorbed in the proximal part of the small intestine with little stimulation to the distal part of the small intestine, so it cannot fully release its endocrine function of lowering blood sugar, which may be an important reason for the occurrence of elevated glucose tolerance and diabetes. Gastrointestinal diversion surgery eliminates the stimulation of food to the proximal small intestine, but greatly increases the stimulation to the distal small intestine, thus changing the endocrine status of the small intestine and achieving the purpose of treating diabetes.