Diabetes has become one of the chronic diseases that seriously threaten human health. Coronary heart disease, nephropathy, retinopathy and neuropathy caused by diabetes are the main causes of death and disability of patients.
According to the WHO, the incidence of diabetes in the world is increasing significantly year by year. The prevalence of diabetes in adults in China is about 9.7%, with a total of about 90 million, of which T2DM accounts for 90%. 2007-2008 survey of the Chinese Medical Association Diabetes Society shows that the prevalence of diabetes in China has reached 9.7%, about 92.4 million, and the number of pre-diabetes has reached 148 million. There will be 1.01 million new diabetic patients every year, with 2,767 new diabetic patients every day. Diabetes has become the third largest non-communicable disease after cardiovascular diseases and tumors, and is a worldwide public health problem that seriously threatens human health.
Traditional treatments for diabetes include dietary control, exercise, oral hypoglycemic drugs and insulin injections, etc. However, these treatments can hardly cure diabetes fundamentally, keep patients’ blood glucose stable for a long time, and prevent the occurrence and development of various complications of diabetes fundamentally.
Diabetes usually coexists with obesity, and about 90% of T2DM patients are obese or overweight. In recent years, with the booming development of bariatric surgery in China and abroad, more and more obese patients are undergoing bariatric surgery and achieving good weight loss results. In addition, these bariatric surgeries are effective in reducing the patient’s weight and improving the co-existing disorders of glucose metabolism in most patients. After surgery, some obese patients have experienced clinical remission or even complete clinical remission of their preoperative diabetes. Even, there are also studies and evidence that bariatric surgery has better therapeutic effect for low weight type 2 diabetes, but further studies are needed to clarify the relationship between weight and the efficacy of bariatric surgery in treating diabetes, which is more important for the Asian population, including Chinese, whose BMI is generally at a lower level.
I. Current status of research.
1.Domestic and international development and efficacy
Since the 1980s, the United States began to implement gastric diversion surgery mainly for the treatment of morbidly obese type 2 diabetic patients and unexpectedly found that patients could get complete diabetes remission after surgery. In 2009, the American Diabetes Association (ADA), the world’s leading authority on diabetes treatment, included gastric bypass surgery in its 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 curable gastrointestinal disease. Foreign studies reviewed the clinical data of 22,094 patients with type 2 diabetes who underwent gastric bypass surgery between 1990 and 2002, suggesting a weight loss rate of 61.6% and a complete remission rate of diabetes of 83.6%, as well as significant improvements 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 the surgical procedure. More than 4,000 cases have also been successfully completed in Taiwan, with stable postoperative results expected to be maintained over the long term. 2012 saw several consecutive papers in the New England Journal affirming the definitive effect of surgery on the treatment of diabetes. A recent large-scale comprehensive analysis reported on 135,246 patients who underwent bariatric surgery, of which 4,070 had complete follow-up with diabetes. 86.6% of patients had improvement in their diabetes and 78.1% achieved complete remission of their diabetes. Diabetes remission was positively correlated with weight loss.
Serum insulin, glycated hemoglobin and blood glucose decreased in postoperative patients. A 10-year follow-up study in Sweden also showed remission rates of 72% (2 years) and 37% (10 years) in the surgical group and 21% (2 years) and 13% (10 years) in the medical treatment group.
The benefits after surgical remission of diabetes are also significant, as Adams et al. reported a reduction in diabetes-related mortality (92%) after 7 years of treatment with gastric bypass surgery. Patients <65 years of age showed efficacy after 6 months, while patients >65 years of age showed efficacy after 11 months.
2. Mechanism of surgical treatment
The main mechanisms of gastrointestinal surgery for the treatment of diabetes mellitus may be.
(1) Reduced food intake and absorption, thus reducing energy intake and glucose metabolic load.
All bariatric surgery patients will have very low caloric intake in the short term. Previous studies have shown that 1 week of very low caloric intake can achieve the effect of reducing insulin resistance, followed by weight loss of patients, which also has long-term effects on reducing intra-abdominal fat and insulin resistance.
(2) Effect of Ghrelin.
Ghrelin-like growth hormone is mainly secreted by the bottom of the stomach and is the gastrointestinal hormone in charge of appetite control.
(3) The effect of duodenal isolation.
The duodenum is the body’s primary control of oral glucose metabolism, and recent studies have shown that the development of diabetes is related to problems in the duodenum’s blood glucose regulation mechanism. Most patients have abnormal elevations of glucagon and VIP, and isolation of food into the duodenum after surgery can reduce abnormal intestinal hormonal responses, thereby improving the condition of diabetes.
(4) Remote intestinal stimulation for weight loss surgery allows food to enter the remote intestine rapidly, causing many intestinal hormones, such as glucagon-like peptide?
1 (GLP-1) and tyrosine (PYY) increase rapidly, which is a new drug switch in the treatment of diabetes.
II. Introduction of surgery
1.Surgery indications
The current indications for surgery in China include
(1) Patient age ≤ 65 years.
(2) The patient’s duration of T2DM ≤ 15 years.
(3) Patients with islet reserve function above 1/2 of the lower limit of normal and C-peptide ≥ 1/2 of the lower limit of normal.
(4) Patients with T2DM type 2 diabetes mellitus with high obesity, BMI?35kg/m2, surgery is preferred; BMI?28kg/m2, surgery can be chosen if drug treatment is unsatisfactory. However, surgery should not be the last treatment option for diabetic patients, but should be considered as one of the treatment options in the earlier stages of obese diabetes treatment.
(5) The patient’s waist circumference diabetes mellitus is very closely related to insulin resistance. Insulin resistance and intra-abdominal fat accumulation are inextricably linked, so a patient with a waist circumference of >90cm in men and >80cm in women is also an option for surgical treatment.
(6) The presence or absence of comorbidities in diabetes is likely to cause large and small vessel lesions. (6) The presence of comorbidities Diabetes is prone to large and small vessel lesions. Special attention should be paid to visual changes, cardiac and renal function, and further investigations should be arranged if there are signs of vascular disease. If the patient is blind, has significant kidney damage or has a history of myocardial infarction or stroke, any surgical treatment is not recommended.
(7) At the same time, the patient is not severely mentally impaired or intellectually challenged; the patient fully understands the surgical modalities for the treatment of diabetes, understands and is willing to assume the risk of potential complications of the surgery, understands the importance of postoperative changes in diet and lifestyle habits and is willing to tolerate them; and the patient can actively cooperate with postoperative follow-up are also factors to be considered in the selection of surgery. Although for patients with low BMI diabetes, some studies have reported that postoperative patients also have a good rate of complete remission of diabetes at monthly follow-up, the current academic mainstream studies do not recommend surgery for patients with low BMI diabetes and are limited to small-scale exploratory studies.
2.Surgery modality
Diabetic surgery was inspired and developed by bariatric surgery. There are various types of bariatric surgery, including vertical gastric banding, adjustable gastric banding, biliopancreatic bypass, biliopancreatic bypass, duodenal diversion, gastrojejunostomy bypass, long branch gastrojejunostomy bypass, banded gastrojejunostomy bypass and sleeve gastrectomy. However, after evidence-based medical testing, many of these procedures have been abandoned by surgeons, and now the mainstream procedures are mainly divided into laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastrojejunostomy bypass.
(1) Laparoscopic sleeve gastrectomy: 4-8 cm of the gastric sinus above the pylorus is preserved in the direction of the lesser curvature of the stomach, and a large portion of the stomach is removed so that the remaining stomach is “banana-shaped” about the diameter of the gastroscope, with a volume of about 100 mL. This procedure is indicated for high-risk and extremely obese patients. After 6 to 12 months, it is expected that 30% to 60% of the overweight portion of the body will be lost. The procedure does not alter the physiology of the gastrointestinal tract and does not produce nutrient deficiencies. The gastric resection is performed with a cutting anastomosis. Complications to be prevented are bleeding, leakage and stricture of the incision margin. The resected stomach cannot be recovered. For patients with very severe obesity or at high risk for other serious obesity complications, this procedure can be performed first in order to control the patient’s obesity relatively quickly and eliminate the associated risk factors earlier by using relatively safe means. Thereafter, the need for second-stage surgery is determined by the patient’s postoperative weight loss and the expectation of the weight loss results. Second-stage surgery is usually performed 6-18 months after the first-stage surgery.
Surgical steps.
① freeing the greater curvature of the stomach starting from the sparse vascularization of the greater curvature.
(ii) Separation of the gastrocolic ligament toward the fundus and left side of the cardia to ensure complete hemostasis.
③ Separation of the gastrocolic ligament at the fundus of the stomach.
④ separation of the posterior gastric wall and fundus of the stomach.
⑤ separating the gastrocolic ligament toward the sinus part of the stomach to 6 cm above the anterior pyloric vessels, starting partial resection of the stomach with a linear cutting closure, leaving a gastroscope (about 1.2 cm in diameter) or other tubular guide on the lesser curved side.
(vi) Removal of the majority of the stomach leaving the tubular stomach.
(vii) The final cut on the left side of the cardia to ensure total resection of the fundus, but not to cause stenosis.
After completion of Sleeve surgery
(2) Laparoscopic Roux-en-Y gastrojejunostomy bypass: After surgery, only a small gastric sac with a capacity of about 25 ml is retained, and the gastric sac should be completely separated from the distal side of the stomach. The perioperative mortality rate is about 0.5% and the incidence of surgical complications (anastomotic leak, bleeding, incisional infection, pulmonary embolism, etc.) is about 5%. Long-term complications may include tipping syndrome, anastomotic stenosis, marginal ulceration, closure line dehiscence, and internal hernia. Clinical observations have confirmed that the mortality rate of RYGBP surgery is 0% to 1.5%, and the main complications are anastomotic leak, pulmonary embolism, and intestinal obstruction, with an incidence of 0.6% to 6%. The overall efficiency of gastric diversion surgery for type 2 diabetes is 95%, and the remission rate is 83%. Moreover, the efficiency of the surgery is 100% for type 2 diabetes with a disease duration of less than five years, and about 70% for those with a disease duration of more than 10 years. Depending on the insulin resistance and islet cell function of each individual, the onset of action can be as fast as 3 weeks and as slow as one year. Lifetime Vit B12 supplementation is required, as well as iron, Vit B complex, folic acid and calcium supplementation as needed.
Surgical steps.
① Inflation of the balloon with balloon gastric tube 30ml (surgeons have different perceptions of the size, general consensus cannot be greater than 50ml)
②Marking of the small gastric sac reserved.
③ separation of the fundus of the stomach.
④ first cut of reconstructed small gastric sac by separating the posterior gastric wall on the side of the greater curvature.
⑤ reconstruction of the successful small gastric sac.
⑥small gastric sac opening ready for gastrointestinal anastomosis.
⑦ measuring the length of the open small intestine and reserving the length of the biliopancreatic branch small intestine about 100 cm (the exact length varies among surgeons, but it is generally emphasized that the length of the biliopancreatic branch small intestine plus the length of the gastrointestinal branch small intestine must be at least greater than 200 cm)
⑧ gastrointestinal anastomosis with occluder closure, generally less than 2 cm.
⑨ suturing of the gastrointestinal anastomosis
⑩ completion of gastrointestinal anastomosis reconstruction.
⑪ dissociation of the small intestine
⑫enteroenteric anastomosis; ⑫enteroenteric anastomosis
⑬after enteroenteric anastomosis
⑭ closure of the post-enteroenteric anastomosis breach by a closure device
⑮Suture closure of post-enteroenteric anastomosis breach.
⑯Peterson fissure.
⑰ Closure of tethered laceration (Peterson’s laceration)
⑱ closure of the small intestine mesenteric fissure.
3. Postoperative follow-up
(1) Postoperative guidance: lifelong follow-up after surgery is required.
(1) At least 3 outpatient follow-up visits, as well as more follow-up visits by telephone or other means, are required in the first year after surgery.
②The main contents of follow-up visits include the patient’s blood glucose, glycosylated hemoglobin, insulin, C-peptide, as well as the patient’s weight, nutritional status, and mental status.
③The purpose of the follow-up visit is to grasp the control of T2DM, whether the patient still needs diet or drug adjuvant therapy, and to monitor whether the patient has diabetes-related complications and whether there is improvement after surgery.
④ Monitor for the occurrence of surgical complications and for any nutrient, vitamin or mineral deficiencies so that timely therapeutic adjustments can be made. For some discomfort of the patient, necessary medication and psychological counseling are also required. For example, if the patient has symptoms of chronic heartburn and acid reflux, appropriate medication to inhibit gastric acid and protect gastric mucosa can be given. All follow-up contents should be detailed and exact, and filed in time.
(2) Dietary guidance: It is a crucial part to ensure the effect of surgical treatment, avoid long-term postoperative complications and improve various postoperative discomforts of patients. The purpose is to form new dietary habits to promote and maintain the improvement of glucose metabolism, while supplementing essential nutrients and avoiding patients’ discomforts. The measures are to drink adequate amounts of fluids, eat sufficient protein, and supplement with essential vitamins and minerals.
①Low sugar and low fat diet.
②Avoid over-eating.
③Eat slowly, about 20-30 min per meal.
④Chew and swallow slowly, avoiding foods that are too hard or large.
⑤Eat protein-rich foods first and avoid high-calorie foods.
⑥Depending on the type of surgery, some require daily supplementation of essential vitamins and mineral supplements according to instructions.
⑦Ensure adequate daily fluid intake and avoid carbonated beverages.
III. Efficacy evaluation
Referring to the 2010 China Diabetes Surgery Summit and Consensus Conference and the opinions of the Chinese Diabetes Surgery Treatment Expert Group, the following manifestations of T2DM healing or remission after surgery can be judged as effective treatment.
(1) Patients who are treated with diet, oral medication or insulin before surgery, no longer need any of the above interventions after surgery, and can maintain random blood glucose <11.1mmol/L, fasting blood glucose <7.0mmol/L, oral glucose tolerance test 2h blood glucose <11.1mmol/L, glycosylated hemoglobin <6.5% for a long time, can be judged as clinical Complete remission.
(2) Those who need to use insulin to control blood glucose before surgery, but only need oral medication or diet adjustment to control blood glucose to normal after surgery, can be judged as clinical partial remission.
(3) Those who need oral hypoglycemic drugs to control blood glucose before surgery, but only need dietary adjustment to control blood glucose to normal after surgery, can be judged as clinical partial remission.
(4) There are obvious complications of T2DM before surgery, such as diabetic nephropathy and diabetic retinopathy. If these diabetic complications disappear or remit after surgery, the treatment is judged to be effective.
(5) In addition to T2DM, other manifestations of metabolic disorder syndrome, such as obesity, hyperlipidemia, hypertension, respiratory sleep apnea syndrome, etc., are present before surgery, and the disappearance or remission of these metabolic disorder syndrome after surgery is also judged as effective treatment.
Strict selection of patients according to the indications of surgery and successful implementation of surgery are only the first step in the treatment of diabetes mellitus with bariatric surgery, but strict postoperative follow-up and standardized patient management are more important, which is not only a crucial part of maintaining and monitoring the surgical effect, ensuring good long-term glycemic control and avoiding long-term postoperative complications, but also an important source for obtaining objective and systematic data on the long-term efficacy and safety of bariatric surgery. It is also an important source for obtaining objective and systematic data on the long-term efficacy and safety of bariatric surgery.
In order to ensure the healthy development of bariatric surgery for type 2 diabetes, which is an emerging treatment method for diabetes, each medical unit in China should pay attention to the following points when carrying out bariatric surgery for diabetes.
1. the indications for surgery should be mastered in strict accordance with the recommendations of relevant guidelines and norms.
2. surgeons should improve their surgical skills through various trainings to ensure the standardization and safety of the surgical sessions
3, the establishment of standardized treatment process of preoperative registration, assessment and postoperative follow-up and management, efficacy assessment by a multidisciplinary professional team composed of surgery, internal medicine, nursing, psychology, nutrition, etc. to implement the standardized treatment process.
Fourth, the prospect of surgical treatment of diabetes
In recent years, many medical units in China have been carrying out clinical and research work on bariatric surgery for the treatment of diabetes and have gradually changed from the initial surgical mode of only surgeons to a multidisciplinary cooperation and integrated treatment and management mode. Many clinical and basic research articles have been published in authoritative journals at home and abroad, and many high-level clinical and scientific research projects have been initiated. However, there is a blindness and arbitrariness in the development of diabetes surgery in individual hospitals, and the indications for surgery are not strictly grasped and the treatment process is not standardized, which affects the effectiveness and safety of surgical treatment, therefore, there is an urgent need to establish a standardized and standardized development system in the field of diabetes surgery in China.
Surgical and other non-pharmacological interventions for diabetes and obesity provide new therapeutic approaches for the treatment of diabetes and obesity. Because of the multi-specialty nature of this treatment and the specificity of the patient population, bariatric surgery and other forms of interventions are expected to develop into an independent discipline and simultaneously drive the development of related disciplines. Basic and clinical research related to bariatric surgery will greatly improve our understanding of the pathogenesis of diabetes and other related diseases and ultimately improve the diagnosis and treatment of the disease.
Although the surgical treatment of diabetes mellitus has been written into the treatment guidelines in Europe and the United States as well as in China, it has not been carried out for a long time in China, especially the laparoscopic completion of the surgery has only recently gained widespread attention, thus we have accumulated limited experience, and in the process of preparation, we have referred to the experience of our colleagues and the consensus formed at the symposium. We hope that in the near future, through our joint efforts, we will find an individualized surgical plan suitable for diabetic patients in China.