First, the current situation of diabetes surgery treatment
The latest literature reports that the number of diabetic patients in China has reached 92 million, and 148 million people are the “reserve army” of diabetes, 60% of diabetic patients are undiagnosed, and type 2 diabetes accounts for more than 90% of diabetic patients. type 2 diabetes is traditionally considered a medical disease, and the common treatment methods include diet control, exercise, oral hypoglycemic drugs, and insulin. increased exercise, oral hypoglycemic drugs, and the use of insulin. However, prospective studies at home and abroad have shown that all the above-mentioned medical treatments can control blood glucose, but still cannot prevent the emergence and further aggravation of various diabetic complications. Studies by the World Health Organization have shown that the risk of type 2 diabetes in obese people is three times higher than that of normal people, and about 50% of obese people are at risk of developing diabetes, while 80% of type 2 diabetes patients are overweight or obese at the time of diagnosis.
In the 1950s, bariatric surgery was introduced for the treatment of obese patients, and long-term follow-up found that obese patients lost significant weight after bariatric surgery, and the accompanying type 2 diabetes also improved to varying degrees. However, the treatment effect of different types of bariatric surgery on type 2 diabetes differs greatly, among which the treatment effect of gastric diversion surgery is the best, up to 83-95%, and it is the most commonly used procedure for the treatment of type 2 diabetes with obesity in clinical practice. After surgery, the patient has a diversion of food from the upper gastrointestinal tract, which no longer passes through the distal part of the stomach, duodenum and upper jejunum. As a result, the upper GI tract no longer receives food stimulation, the insulin resistance factor secreted by the K cells of the GI mucosa disappears, and the body’s insulin resistance is eliminated. At the same time, after the surgery, the incompletely digested food can enter the lower and middle digestive tract earlier, and this section of the digestive tract accepts the undigested or incompletely digested food earlier, which leads to an increase in the secretion of hormones and increases insulin sensitivity through the “intestine-islet axis”, while promoting insulin secretion and reducing islet apoptosis. It also promotes insulin secretion and reduces islet apoptosis and proliferation to control blood glucose.
In 2009, the American Diabetes Association (ADA), the world’s leading authority on diabetes treatment, included gastric diversion surgery in the Diabetes Prevention and Control Guidelines and established it as a routine treatment for diabetes. In September of the same year, the European Diabetes Association confirmed diabetes as a surgically curable gastrointestinal disease. 2011, the International Diabetes Federation (IDF) published an expert consensus that surgery is an acceptable treatment option for Asian patients with type 2 diabetes whose body mass index (BMI) is ≥32.5 Kg/m2; for BMI between 27.5 and 32.5 For patients with BMI between 27.5 and 32.5 kg/m2, surgery should be one of the treatment options for patients whose diabetes cannot be effectively controlled by pharmacological therapy, especially those with cardiovascular disease risk factors.
Second, the mechanism of surgical treatment of diabetes mellitus
At present, domestic and foreign experts believe that the main mechanism of surgical treatment of diabetes is.
(1) reduce food intake and absorption, thus reducing energy intake and glucose metabolic load; (2) reduce the patient’s weight and reduce insulin resistance caused by fat accumulation due to simple obesity; (3) change the secretion of hormones in the intestine-insulin axis after gastrointestinal tract reconstruction, thus improving glucose metabolism.
III. Indications for surgical treatment of diabetes mellitus
1. In May 2011, the Chinese Medical Association Diabetes Branch and the Chinese Medical Association Surgery Branch published the latest expert consensus on surgical treatment of diabetes, and the indications for surgical treatment of diabetes are.
(1) In Asian populations with T2DM with or without comorbidities with BMI ≥ 35, weight loss/gastrointestinal metabolic surgery can be considered; (2) In Asian populations with BMI 30-35 and T2DM, weight loss/gastrointestinal metabolic surgery should be one of the treatment options when it is difficult to control blood glucose or comorbidities with lifestyle and medication, especially when there are cardiovascular risk factors; (3) In Asian populations with BMI 28-29.9 in Asian populations with comorbid T2DM and with centripetal obesity (waist circumference >85 cm in women and >90 cm in men) and at least two additional criteria for metabolic syndrome: high triglycerides, low HDL cholesterol levels, and hypertension. Weight reduction/gastrointestinal metabolic surgery should also be considered as a treatment option for the above patients; (4) For adolescents with BMI ≥ 40 or ≥ 35 with severe comorbidities; and who are ≥ 15 years old, skeletally mature, and in grade 4 or 5 by Tanner developmental classification, LAGB or RYGB may also be considered as a treatment option for the above patients with informed consent of the patient; (5) T2DM patients with a BMI of 25 to 27.9 should undergo surgery with the patient’s informed consent, strictly according to the study protocol. However, the nature of these surgeries 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) T2DM patients aged <60 years or in good general physical condition with low surgical risk; IV. Minimally invasive laparoscopic surgery for type 2 diabetes mellitus 1. Advantages of minimally invasive surgery Less trauma, faster recovery, lower risk, less postoperative pain, better cosmetic results, better small wound infection rate and few complications. Experts suggest that minimally invasive surgery must be chosen to avoid more damage to the body.
2, Types of laparoscopic diabetes surgery
The common restrictive, malabsorptive and both combined surgeries have good efficacy for type 2 diabetes. According to a large amount of literature, the complete remission rate of type 2 diabetes by three types of laparoscopic weight reduction surgery after 1-3 years of follow-up is 48%-73% for laparoscopic gastric banding (LAGB), 66%-88% for laparoscopic sleeve gastrectomy (LSG) and 83%-95% for laparoscopic gastric diversion surgery (LRYGB). Currently, the most widely accepted surgical procedure internationally is gastric diversion surgery.
3.Laparoscopic gastric diversion surgery
In 2009, the American Diabetes Association (ADA), the world’s leading authority on diabetes treatment, included gastric diversion surgery in the Diabetes Prevention and Control Guidelines, recommending it as one of the conventional treatments for diabetes. In September of the same year, the European Diabetes Association confirmed diabetes as a surgically curable gastrointestinal disease. 2011, the International Diabetes Federation (IDF) published an expert consensus that surgery is an acceptable treatment option for Asian patients with type 2 diabetes with a body mass index (BMI) ≥ 32.5 Kg/m2; for patients with a BMI between 27.5 and 32.5 kg/ m2, and for patients with BMI between 27.5 and 32.5 kg/ m2, surgery should be one of the treatment options for patients whose diabetes cannot be effectively controlled by pharmacological therapy, especially those with cardiovascular disease risk factors.
3.1 Features of laparoscopic gastric diversion surgery?
1. minimally invasive technique, less trauma, faster recovery, less recurrence, lower risk and fewer complications.
2.Treatment of diabetes, blood sugar returns to normal, most patients get rid of lifelong medication or insulin injection; 3.Obese patients lose weight and can get good weight loss effect; 4.Avoid the occurrence of disability and death caused by type 2 diabetes; 5.Patients can resume normal diet and free life; 6.A series of complications caused by diabetes (hypertension, hyperlipidemia, etc.) are cured or improved.
3.2 The main surgical procedure of laparoscopic gastric diversion surgery uses minimally invasive surgical techniques, only 4-5 small holes of 0.5-1.2 cm in diameter are made in the patient’s abdomen, and the surgeon understands the situation inside the patient’s abdomen by watching a TV screen during the surgery. The rest of the stomach is not removed, but is completely stapled with mechanical sutures to separate it from the gastric sac. Food flows directly from this newly formed gastric sac outlet into the lower part of the jejunum, bypassing the duodenum and upper jejunum.
3.3 The efficacy of laparoscopic gastric diversion surgery for type 2 diabetes using laparoscopic Roux-en-Y gastric diversion (LRYGB) for the treatment of obesity and type 2 diabetes is currently the most advanced and commonly used method internationally. The efficiency of type 2 diabetes treatment can reach 95%, the rate of complete remission of diabetes exceeds 83%, and there is significant improvement in hypertension, hyperlipidemia and sleep apnea. By now, more than one million obese and diabetic patients in Europe and the United States have benefited from surgical procedures. China has also successfully completed more than 4,000 cases of surgery, the postoperative effect is certain and can be expected to maintain long-term.
V. Controversy of surgical treatment of type 2 diabetes
Surgery as one of the effective methods to treat obese type 2 diabetes although the mechanism is not completely clear but its effect and reliability have been fully verified and recommended by domestic and foreign diabetes authorities (IDF, ADA, CDS) and the consensus of metabolic physicians and surgeons. However, the surgical treatment of T2MD in non-morbid obesity is more controversial. Although the Asia-Pacific Center for Bariatric and Diabetic Surgery in Taiwan, the meta-analysis study of surgical treatment of diabetes published in the world’s leading journal Obes Surg or the two randomized trials published online in the New England Journal of Medicine (N Engl J Med) on March 26, 2012 in the United States and Italy, both showed that surgical procedures have different The results both showed that surgery has different degrees of efficacy for type 2 diabetes patients with low BMI, that remission of type 2 diabetes after surgery comes much earlier than weight loss, and that the therapeutic effect of surgery on the treatment of type 2 diabetes cannot be explained by weight factors alone. However, almost all national and international authorities are still very cautious about surgical treatment of non-obese diabetes, and all studies on the surgical treatment of non-obese T2MD indicate that long-term metabolic outcomes remain to be evaluated, and there is a lack of support from the results of RCTs with large samples and high-level evidence-based medical evidence. Fully informed patients, multidisciplinary assessment and ethics committee review are required.
VI. Case presentation.
Zhao Yansong, case: male, 39 years old, BMI 34, T2MD 2 years, fasting blood glucose 17 mmol/L, insulin dosage 65iu (34/32) blood glucose control 8-12 mmol/L, blood pressure 149/94 mmHg.
He underwent laparoscopic gastric diversion surgery (LRYGB) on April 28, 2011, and was discharged 7 days after surgery with 4 kg weight loss and 6.8 mmol/L blood glucose. 2 months and 23 days, discontinued all kinds of hypoglycemic drugs with 15 Kg weight loss, blood glucose: fasting 4.5-5.2 mmol/L, postprandial 5.8-6.2 mmol/L, blood pressure 120/74 mmHg.
At present, 1.5 years after the operation, no glucose-lowering drugs, normal diet, normal work, fasting blood glucose fluctuation in 3.9-5.4mmol/L, blood pressure, blood lipids and other indicators are all normal.
7 days after surgery
2 months and 23 days after surgery
1 year after surgery