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 Diabetes and Metabolic Syndrome Research Group” of the Chinese Medical Association’s Diabetes Branch 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 }/o, respectively, with an overall prevalence of 9.7 }/o, while the prevalence of pre-diabetes was as high as 10.6% and 8.8 }/o. The prevalence of pre-diabetes is as high as 15.5%, according to which it can be projected that the total number of people with diabetes in China has reached 92.4 million, and the number of pre-diabetes has reached 148 million, the treatment of diabetes has become an urgent issue of our attention surgical treatment of diabetes background.
The traditional treatment of diabetes 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, by analyzing the effect of obesity surgery in foreign countries, it was found that after obese patients received gastrointestinal surgery, not only In recent years, foreign countries have analyzed the effect of obesity surgery and found that after obese patients underwent gastrointestinal surgery, not only their weight decreased significantly, but also their complications of type 2 diabetes mellitus (T2DM) were relieved unexpectedly.
The improvement and remission of diabetes by surgical treatment originated from the discovery of Pories et al. When Pories performed gastric bypass surgery (gastric field pass, GBP) for the treatment of morbid obesity, he found by chance that patients with T2 DM combined with significant postoperative weight loss had a rapid return to normal blood glucose, and some patients even did not need glucose-lowering drugs for maintenance. Ferchak et al. found in a prospective controlled study that patients with T2 DM combined with obesity who underwent UBP for obesity had a significantly higher number of cases that did not require drug hypoglycemia and maintained normal blood glucose over time than the non-surgical group, and had a significantly lower incidence of diabetes-related complications and mortality – Aiterburn et al. also found that patients experienced postoperative reductions in systolic blood pressure, A 2008 Australian study showed that surgical treatment of obese T2 DM patients significantly improved the remission rate of T2DM compared with lifestyle 10. In addition, a health economics study 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 for society.
Among the many bariatric surgical procedures, the GBY study was earlier and more numerous, with the best results in the treatment of T2DM patients with obesity, a prospective cohort study from Hong Kong between July 2002 and December 2007 applying laparoscopic adjustable gastric banding (laparosc:n householdadjustable gastric bandirLg, LAGB, _57 cases), laparoscopic gastric sleeve cut J coating ( laparoscopic slee}re gastrectomy , LSG , 30 cases) and laparoscopic gastric bypass ( laparoscopic gastricbypass , LGB , 7 cases) for the treatment of morbid obesity, the mean weight loss rate of patients 2 years after surgery was 34% in the LAGB group , The average weight loss rate 2 years after surgery was 34% in the LAGB group, 51% in the LSG group, 61% in the L(}B group, and significant improvement in obesity-related conditions, including metabolic syndrome, T2 DM, hypertension, and sleep apnea syndrome. Among them, 166 had impaired fasting glucose (IFG) and 247 had T2DM; 1 year after surgery, 78.5% of T2DM patients had normalized fasting glucose, 94.7% of IFG patients had normalized, and 81.5% of T2DM patients had normalized glycosylated hemoglobin (GHB). Yelu, et al. retrospectively studied 400 patients who had undergone GBY and statistically analyzed the comorbid diseases associated with obesity, and at a follow-up of 12 or 8 (0.3-30.6) months, 80% to 100% of the patients’ comorbid diabetes mellitus was relieved or improved, and concluded that the postoperative quality of survival of patients who had undergone GBP surgery 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) of 30 kg/m who have poor glycemic control, and in terms of treatment outcomes alone, Rubino believes that gastrointestinal Rubino believes that P}oux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are more effective in the treatment of T2DM than in obesity, hence the term “metabolic surgery” or “diabetes surgery”. The term “metabolic surgery” or “diabetic surgery” seems to be more appropriate, and it has been clearly stated in the recent Diabetic Surgery Summit that LAGB and LSG are not as effective as RhY GB in the treatment of diabetes, and in general, the efficacy of the procedures including RYGB in the treatment of obese T2DM will diminish as the disease worsens. Recently, the International Diabetes Federation (IDF) issued a bean field statement to formally 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 how to benefit more patients with T2 DM on the basis of standardized treatment, is a current issue worthy of attention.
Indications for metabolic surgery for diabetes mellitus
1, BMI}35 kg/m with or without comorbidities in T2 DM subpopulation, can be considered for weight loss/gastrointestinal metabolic surgery
2. In Asian population with BMI 30-35 k to m 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 with lifestyle and pharmacological treatment, especially when there are cardiovascular risk factors.
3, BMI 28,0-29,9 kg/m in Asian population, if they have combined T2 DM, and have centripetal obesity (waist circumference >85 c,m in women, >90 cm in men) and at least two additional criteria for metabolic syndrome: high glycerol, low HDL cholesterol level, hypertension, weight loss/gastrointestinal metabolic surgery for the above patients can also be considered as one of the treatment options.
4. LAGB or RYGB may be considered as a treatment option for adolescents with BMI 40 lc state rn or 35 kg/m with severe comorbidities and age 15 years with mature gastric and skeletal development and Tanner developmental classification of 4 or 5, with informed consent of the patient.
5. For patients with T2DM with a BMI of 25, 0-27, 9 kKto, surgery should be performed with the patient’s informed consent, strictly in accordance with the study protocol, but the nature of these procedures should be considered purely as part of a pilot study approved in advance by the ethics committee and should not be widely disseminated.
6. Patients with T2 DM who are < 60 years of age or in good general health with low surgical risk:
Contraindications to metabolic surgery for diabetes mellitus
1. Patients with drug or alcohol abuse addiction or uncontrollable mental illness 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 Dn-I whose islet p-cell function has been largely lost
4. Patients with combined bleeding and coagulation disorders, or those whose cardiopulmonary function cannot tolerate surgery
5. Diabetic patients with BMI < 28 kg/m and whose blood glucose can be satisfactorily controlled with medication and insulin.
6.Gestational diabetes and other special types of diabetes mellitus are not covered by surgical treatment for the time being.
Clinical risks of metabolic surgery
(i) 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 for GBP were 0, 29% and 0, 35%, respectively] Buchwald et al. conducted a meta-analysis of the total mortality rate for bariatric surgery, and the 30-d postoperative mortality rate was 0, 1% for LAGS and 0, 5% for GBP. Therefore, although the risk of death is lower than the risk of general surgery, there is still a certain amount of morbidity and mortality.
(II) Recent postoperative complications
In a domestic project, follow-up of 172 simple obese patients after LAGB revealed that early postoperative complications included 4 cases (2, 3) of incisional infection at the buried pump; long-term complications included 2 cases (1, 2%) of delayed infection at the buried pump site, 2 cases (1, 2%0 ) of 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, 7 cases (4, 1 ) gastric bursa dilatation, 1 case (0, 6 C/c) developed chronic intestinal obstruction symptoms 1 year after surgery, 1 case (0, 6 %) patient had mild alopecia, therefore, the 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 surgery is 1, 3% to 4, 0%, while the risk of occurrence after laparoscopic surgery is as high as 1, 8% to 7, 3%, of which, after LAGB surgery, the incidence of small bowel obstruction secondary to intra-abdominal disease is 2, 6% to 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, with an incidence of 1.5% } 5.5%, and the most dangerous leak originates around the anastomosis and L1 nail.
3. Combined with abnormal blood clotting disorders, cardiopulmonary function can not tolerate surgery
Pulmonary embolism is one of the acute complications of bariatric surgery 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 often 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 is rare (but once it occurs, the risk of death greatly increased, foreign literature reported in bariatric surgery after the complication of portal vein injury in 3 cases, the patient still died after liver transplantation)
6, respiratory complications: bariatric surgery is most often complicated by respiratory disease, which may be related to the postoperative management of the community in which the patient is located, and a few clinical centers have reported that the application of continuous positive pressure ventilation (CPAP) after bariatric surgery can reduce the risk of postoperative atelectasis and pneumonia.
(iii) Long-term postoperative complications
1, elimination than the system disease: after bariatric surgery, due to rapid weight loss, resulting in the formation of gallstones, so the incidence of postoperative combined gallstone disease is 3% to 30% [, after the line GBP can be complicated by dumping syndrome according to the survey, 70% of the line GBP patients have varying degrees of gastric light paralysis, mainly manifested as postprandial abdominal distension, abdominal pain, and
2, malnutrition: malnutrition is a possible complication after any kind of bariatric surgery, and should be guided by a dietitian after surgery and followed up for life (1} iron deficiency anemia, folic acid deficiency: a prospective study on GBP found that 36% of women and h% of men had anemia after surgery, 50% of women and 20% of men had a decrease in body iron, and 18% of patients had a decrease in folic acid reserves. A retrospective study also found similar results for iron and folic acid deficiency, with lower levels in menstruating women, (2) vitamin R12 ( VitR12) deficiency: the highest incidence of postoperative VitB12 deficiency was reported at 70%, (, earlier it was thought that the deficiency of ViIBl2 after GBP was caused by a decrease in endogenous factors, but now it is thought to be due to reduced gastric acidity and dietary 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%, with nutritional deficiencies mainly secondary to malabsorption of the gastrointestinal parietal tract, possibly due to reduced nutritional intake, or because the patient was intolerant and could not eat foods rich in certain nutrients after surgery,(3 Calcium and vitamin D (VitD) deficiency: Calcium and VitD deficiency is mainly due to malabsorption of calcium and V itD in the open segment of the intestinal bypass, which in turn leads to further malabsorption of calcium, and 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.
Management of metabolic surgery
1. Pre-operative screening and evaluation: Internal medicine doctors with expertise in endocrinology will screen diabetic patients who are not well treated by internal medicine, and preoperative evaluation will be conducted for patients with indications for metabolic surgery, and these patients will be recommended to comprehensive medical units qualified for metabolic surgery.
2, metabolic surgery treatment: the surgical treatment of T2 DM 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 of level 2 or above. Only after systematic instruction and training can the operation be performed.
3, post-operative follow-up: post-operative need to be familiar with the field of weight loss surgeons and Nei Li a team of doctors and nutritionists for lifelong follow-up of patients dietary guidance is to ensure the effectiveness of surgical treatment, to avoid long-term post-operative well, improve the patient’s post-operative discomfort is a vital part of the formation of new dietary habits to promote the well to maintain the improvement of glucose metabolism, but also to supplement the necessary nutrients to avoid patient Discomfort measures are to drink adequate amounts of fluids, eat adequate protein, and supplement essential vitamins and minerals as follows:
(1) low-sugar, low-fat diet; (2) avoid over-eating; (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 type of surgery, some require daily supplementation of essential vitamins and mineral supplements as directed; O) ensure daily For women of childbearing age undergoing weight loss surgery, pregnancy should be avoided within 1 year after surgery if possible, and if pregnant, the 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 for the rational and effective treatment of diabetes.
It is still believed that medical therapy is the foundation of diabetes treatment and is used throughout the entire course of diabetes treatment; on this basis, medical and surgical physicians need to work together in an active and effective division of labor to minimize the pain and burden of diabetes.