1.Bariatric surgery for type 2 diabetes first appeared in the 1950s, in 1954, Kremen and Linner first reported jejuno-ileal bypass surgery, and then appeared gastric bypass surgery (GBP), gastroplasty, and adjustable gastric banding surgery and other different surgical procedures. 1982, the United States of America, the University of North Carolina surgeon
Pories et al. found by chance that patients with type 2 diabetes who underwent bariatric surgery for the treatment of morbid obesity lost significant weight and had a rapid return to normal blood glucose, and no longer required any glucose-lowering measures for maintenance.
In 1995, Pories et al. reported the results of their study, which showed a cure rate of 83% for type 2 diabetes in 146 patients with obesity combined with diabetes over a 14-year follow-up.
In 1995, Pories et al. This opened up a new avenue of surgical treatment for type 2 diabetes. In 2004 Buchwald
H et al. collected 136 studies published in English literature from 1990 to 2003 and performed Meta-analysis, including 22,094 patients. The results showed that the total effective rate of diabetes treatment in obese patients with combined gastric bypass, biliopancreatic diversion/duodenal switch (BPD/DS) and adjustable gastric banding (GB) reached more than 80%, with a long-term complete remission rate of 76.8%. The rate of improvement of abnormal glucose tolerance reached 86.O%, and most of the patients came off diabetic medications and returned to normal blood glucose and glycated hemoglobin levels. The remission rate of diabetes after biliopancreatic diversion/duodenal switch (BPD/DS) was as high as 98%, followed by Roux-en-Y gastric bypass at 84%. 2009 Buchwald
H et al. included more recent studies with similar results to the former. It is evident that surgery is an effective treatment for type 2 diabetes. The latest study found that the decrease of blood glucose after bariatric surgery is much earlier than the decrease of weight, and the effect of surgery for type 2 diabetes exists independently of the effect of weight loss, so some scholars believe that bariatric surgery should be given a new name of “diabetes surgery”. 2, the mechanism of weight loss surgery for the treatment of diabetes The mechanism of surgery for the treatment of type 2 diabetes is still unclear, there are a variety of hypotheses, it is generally believed that the mechanism of surgery for the treatment of type 2 diabetes is related to the following factors, first of all, weight loss surgery reduces the intake and absorption of food, thus reducing the energy intake and glucose metabolic load, consume their own excess fat, reduce the fat due to simple obesity The insulin resistance caused by the accumulation of simple obesity. Secondly, the gastrointestinal tract reconstruction changes the secretion of hormones in the entero-insulin axis, thus improving glucose metabolism. The gastrointestinal axis is a hot spot for endocrine and gastrointestinal surgery research in recent years. The gastrointestinal tract secretes a variety of hormones related to the regulation of glucose metabolism, including gastropeptide, glucagon-like peptide Il, gastric growth stimulating hormone, leptin, PYY, and adiponectin. The secretion of these hormones is changed after weight loss surgery, which affects the secretion of insulin and the regulation of blood sugar. 3.Surgical methods Bariatric surgery has developed dozens of procedures so far,
With the development and application of laparoscopic technology, most bariatric surgeries can now be performed laparoscopically, thus reducing surgical trauma, post-operative pain and hospitalization time for patients, as well as faster post-operative recovery. The following are the main ones that are more widely performed at home and abroad: 3.1
Laparoscopic gastric adjustable banding laparoscopically separates the perigastric tissues and establishes a posterior gastric access, in which an adjustable silicone band is placed and the two ends are docked and closed to form a loop. Postoperatively, a gastric bursa with a volume of 10-15 mL was formed above the band.
After surgery, a gastric bursa of 10-15 mL is formed above the band, and food enters the bursa and produces a feeling of fullness, resulting in a decrease in food intake and weight loss. This procedure does not destroy the structure and function of the stomach, and the band can be removed after achieving the desired weight loss effect. As a simple restrictive surgery, LAGB has now replaced vertical banding gastroplasty as the most popular bariatric surgery in Europe because of its advantages of less damage, safety and effectiveness, adjustability and recoverability. This procedure has a low remission rate of only 20% for diabetes. 3.2 Roux-en-Y gastric diversion is performed laparoscopically by transecting the upper part of the stomach and dividing the proximal gastric bursa of lO-30 mL. 30 cm below the ligament of Triez
The jejunum is transected about 30 cm below the Triez ligament, lifted and anastomosed with the gastric bursa; the proximal end is anastomosed with the jejunum. This procedure reduces nutrient absorption by shunting while restricting food intake, so it is more effective than simple restrictive surgery for weight loss, and is now the most commonly used bariatric surgery in the U.S. This procedure is also the most effective one for diabetes treatment, with a complete remission rate of 82% to 89%. 3.3
The mechanism of SG for the treatment of diabetes mellitus is not yet clear, but may be related to the changes in the level of hormones such as Ghrelin after SG. The rate of diabetes remission in this procedure is about 50%. 4 Indications for bariatric surgery The Chinese guidelines for the surgical treatment of obesity (2007) suggest the following: those who have one of the following ① to ③ and at the same time have ④ to ⑦ can be considered for surgical treatment.
① confirm that the metabolic disorder syndrome related to obesity has appeared, such as type 2 diabetes, cardiovascular disease, fatty liver, lipid metabolism disorder, sleep apnea syndrome, etc., ② waist circumference ≥ 90 cm in men, ≥ 80 in women
em; triglycerides ≥1.70 mmol/L, and/or fasting blood HDL cholesterol <0.9 mmo/L in men and <1.0 in women
mmol/L, ③ stable or stable weight gain for more than 5 consecutive years, BMI ≥ 32, ④ age 16 to 65 years, ⑤ those with poor or intolerable medical treatment, ⑥ no alcohol or drug dependence, no serious mental disorders, intellectual disabilities, ⑦ patients understand the bariatric surgery procedure and understand and accept the risk of potential complications of surgery; understand the importance of postoperative lifestyle changes and dietary habits for postoperative recovery The patient understands the importance of postoperative lifestyle and diet changes to postoperative recovery and has the ability to tolerate them. The Chinese Expert Guideline on Surgical Treatment of Diabetes (2010) recommends that patients with diabetes who meet the following indicators can be treated surgically: (1) BMI ≥ 27.5 (waist circumference ≥ 90 cm for men and ≥ 80 cm for women), and (2) patient age.
The patient’s age is ≤ 65 years, ③ the patient’s duration of T2DM is ≤ 15 years, ④ the patient’s islet reserve function is above 1/2 of the lower limit of normal (C peptide ≥ 1/2 of the lower limit of normal.
cm, men 102 cm), even if the BMI is not high, should also be considered to have the indications for surgery. 5, the prospect of surgical treatment of diabetes through surgery to treat obesity and related complications has become the world’s main way to treat serious obesity, long-term experimental and clinical practice has proved that surgical treatment for type 2 diabetes is effective in the long term. In 2008, the European Society for the Study of Diabetes reached a consensus that “diabetes” is a surgically curable disease of the gastrointestinal tract, and in 2009, the American Diabetes Association (ADA), the world’s leading authority on diabetes treatment, identified gastric diversion as a routine treatment for diabetes. In 2009, the American Diabetes Association (ADA), the world’s leading authority on diabetes treatment, established gastric diversion as a routine treatment for diabetes, and more than one million obese and diabetic patients in Europe and the United States have benefited from the surgery. More than 1 million obese and diabetic patients in Europe and the United States have benefited from surgery. In Taiwan, China, more than 4,000 cases have been successfully completed, with positive and long-term postoperative results. In mainland China, surgery for diabetes is gradually being carried out. Surgery has opened up a new way for the treatment of type 2 diabetes.