Current status of the incidence and dangers of diabetes mellitus
According to the World Health Organization, the incidence of diabetes mellitus in the world has been increasing significantly year by year. The latest statistics show that the prevalence of diabetes among adults in China is about 9.7%, with a total of more than 92 million people, of which type 2 diabetes mellitus (T2DM) accounts for 90%, and there are 143.2 million pre-diabetics. Studies have found that the incidence of diabetes increases significantly with increasing body weight, as seen in the graph below, when the body mass index BMI (weight (Kg)/rise (m) squared) increases to 30, the incidence of diabetes reaches 18.50%.
Diabetes mellitus is a common endocrine metabolic disease, and data show that 70% of diabetic patients die from complications. Diabetes causes acute and chronic complications, among which acute complications include diabetic ketoacidosis, diabetic lactic acidosis, etc.; chronic complications include retinopathy and blindness, diabetic nephropathy (leading to renal failure in severe cases), diabetic foot (leading to amputation in severe cases), macroangiopathy (leading to myocardial infarction and cerebrovascular disease in severe cases), etc.
Traditional treatments for type 2 diabetes include diet control, exercise, oral hypoglycemic drugs and insulin injections, etc. However, these treatments can hardly cure diabetes fundamentally, keep patients’ blood sugar stable for a long time, and prevent the occurrence and development of various complications of diabetes fundamentally. Strict dietary control and repeated fluctuations in blood glucose levels cause constant mental stress to patients and affect the quality of life. Patients desperately need a treatment that provides good control of diabetes and its complications.
Effectiveness of surgical treatment of type 2 diabetes
Clinical observations have found that within weeks of undergoing gastric bypass surgery, the vast majority of patients with type 2 diabetes have good control of their blood glucose, no longer require medication for blood glucose control or are significantly less dependent on medication, and their hypoglycemic effect can remain stable. In an analysis of more than 22,000 obese patients who underwent bariatric surgery such as gastric bypass, the vast majority of patients experienced significant remission of their diabetes early (2 to 8 weeks) after bariatric surgery, with a remission rate of 90.6% for type 2 diabetes after gastric bypass surgery. The American Diabetes Association (ADA) has included surgical treatment of diabetes in its 2009 diabetes treatment guidelines.
In recent years, through surgical treatment of non-obese (body mass index BMI 24-35 Kg/m2) type 2 diabetes patients, it was found that the cure rate of type 2 diabetes by gastric bypass surgery reached about 95%, and most type 2 diabetes patients completely stopped medication within a short time after surgery, which provides a good prospect for surgical treatment of type 2 diabetes.
The figure below suggests that insulin dosage is significantly reduced as blood glucose gradually decreases after surgery, and insulin therapy can be stopped one week after surgery. Moreover, according to the results of follow-up up to 14 years, the control of diabetes after surgery is long-term and stable.
How is diabetes surgery performed?
In gastric bypass surgery for type 2 diabetes (see diagram), a gastric bursa is first created in the proximal part of the stomach and the distal stomach is completely separated from the bursa. Food passing through the bursa will go directly into the reconstructed jejunal pathway, bypassing the duodenum and part of the jejunum. Minimally invasive gastric bypass surgery is easy and quick, requiring only four to five small holes of 5mm to 10mm, operated laparoscopically, and takes about 1 and a half hours, with minimal trauma, quick recovery, and low risk, and can be discharged 3 to 5 days after surgery. Generally, blood glucose metabolism can be significantly improved in 3 to 15 days after surgery.
Diagram of gastric bypass surgery There are only 5-6 very small incisions after surgery
Compared to other surgeries, gastric bypass surgery not only reduces the volume of the stomach, but also opens up about 100 to 200 cm of the small intestine to achieve weight loss and diabetes control through a combination of intake control and absorption reduction. The procedure is also more humane, as the post-surgical restrictions on eating are greatly reduced, eliminating the physical and mental burden of a harshly controlled diet for the patient.
Today, minimally invasive gastric bypass surgery has become an internationally advanced treatment for diabetes. Clinical observations have shown that, in addition to normal blood glucose, a range of metabolic abnormalities associated with diabetes have been better corrected after surgery, and complications of diabetes have been significantly improved, such as hypertension and dyslipidemia, which have gradually normalized.
What kind of people are suitable for surgery for diabetes?
According to the guidelines on metabolic surgery for type 2 diabetes of the Chinese Medical Association’s Division of Diabetes and the Endocrine Surgery Group of the Society of Surgery, the following groups are suitable for surgical treatment of diabetes.
1.Bariatric/gastrointestinal metabolic surgery can be considered in Asian populations with BMI ≥ 35 kg/m2 with or without comorbidities.
In Asian populations with a BMI of 32-34.9 kg/m2 and type 2 diabetes, weight loss/gastrointestinal metabolic surgery should be one of the treatment options when lifestyle and pharmacological treatments are difficult to control blood glucose or comorbidities.
3. In Asian populations with a BMI of 30-31.9 kg/m2, if they have combined type 2 diabetes and have centripetal obesity (waist circumference >85 cm in women and >90 cm in men) and meet at least two additional criteria for metabolic syndrome: high triglycerides, low HDL cholesterol levels, and high blood pressure. Weight reduction/gastrointestinal metabolic surgery for the above patients should also be considered as one of the treatment options.
4. Surgery in type 2 diabetic patients with a BMI of 28 to 29.9 kg/m2 should be performed with the patient’s informed consent and strictly according to the study protocol. However, the nature of these surgeries should be considered, purely and exclusively as part of experimental studies approved in advance by the ethics committee, and should not be widely promoted.
Since obesity in the country is mostly abdominal and has a higher risk of cardiovascular accidents and other complications, surgery should be considered more aggressively when the waist circumference is ≥90 cm in men and ≥80 cm in women.
Frequently asked questions about gastric bypass surgery
I. What are the criteria for remission of type 2 diabetes after surgery?
After surgery, type 2 diabetes can be considered to be in remission if A1c≤6.5%, fasting blood glucose≤7.0mmol/L and 2h blood glucose≤10mmol/L can be achieved with lifestyle treatment only, without any drug treatment.
B. What is body mass index?
Body mass index (BMI) = weight (kg)/height (m) squared.
C. What are the complications of gastric bypass surgery?
The most common complications of this surgery are intraoperative and postoperative bleeding, anastomotic fistula, anastomotic stricture, and so on. Experienced surgeons are able to avoid these complications; usually major complications occur 1-2 days after surgery, after which the patient can be discharged from the hospital after about 5 to 7 days of observation, and after discharge, the patient should return to the hospital once every 3 months to 6 months to check the health condition and the effect of treatment, and be given dietary guidance and exercise guidance by the doctor, etc.; followed by follow-up visits after one year and After that, we will follow up with you by telephone.
Some problems related to surgery
It takes about half a month from the time of hospitalization to the time of discharge. It is recommended that people who are planning to have this surgery should take half a month of vacation, so that there will be more time.
2.After the surgery, you need to be hospitalized for about one week. Depending on the nature of the work, you can do some housework and work with less activity after discharge, and you can generally recover in 1-2 months.
3.The entire gastric bypass surgery procedure usually takes about 2 hours, depending on the patient’s age and degree of obesity: the greater the weight and the older the person, the longer the surgery will take.
4, Female patients will not be affected by this surgery.
5.After the surgery, there is usually no need for harsh diabetic diet control, and the control in the type of food and the amount of food eaten can be significantly reduced.
6.Will eating less after surgery cause malnutrition? Because the gastrointestinal tract of the surgical absences is determined according to individual circumstances, malnutrition will not usually occur.
7.The cost of the whole operation is 40,000-60,000 RMB, and if complications occur after the operation, the cost will be relatively higher. At present, the occurrence of complications has been strictly controlled and is very rare.
V. What is the risk of gastric bypass surgery?
According to the statistics of the United States, the mortality rate of weight loss surgery is about 0.4%, which is a very low risk surgery in terms of surgery.
Will there be any nutritional imbalance after gastric bypass surgery?
Generally, a certain amount of vitamin supplementation is required after surgical weight loss surgery. Since gastric bypass surgery changes the structure of the gastrointestinal tract, the absorption function of the gastrointestinal tract is affected to a certain extent. It is recommended that gastric bypass patients take some vitamins according to the review.
7. Should I restrict my diet after gastric bypass surgery and will I regain weight after surgery?
Dietary control is mainly during the first three months after surgery: food intake should be relatively small during these three months and no stimulating food should be consumed, with the least amount of food consumed during the first month. After three months, the dietary requirements can be gradually relaxed, and after that there are no special requirements. Theoretically, lifelong follow-up is required after surgery, with the interval between follow-up visits being gradually extended.
VIII. Does laparoscopic surgery increase the risk of surgery?
No. The risks of laparoscopic surgery are the same as those of incisional surgery. The benefits of laparoscopic surgery include reduced discomfort, shorter hospital stays, earlier return to work, and reduced invasiveness.
How soon after surgery can I walk around?
Almost immediately after the surgery, you will be asked to get up and walk around. On the night of the surgery, patients ask to walk or stand at the bedside, and the next day and beyond, they ask to walk several times. When you leave the hospital, you will be able to take care of all of your personal needs, but you will still need help with shopping, lifting heavy objects, and riding in the car.