1.The current situation of obesity in China
The incidence of obesity is increasing year by year and has become a serious threat to human health.
2005 China’s population nutrition and health survey shows
Overweight rate of 22.8%, about 200 million, 30.0% in large cities, compared with 1992, an increase of 40.7% in the emergency department of the second hospital of Hebei Medical University Wu Weizhong
Obesity rate of 7.1%, 60 million, 12.3% in large cities, compared to 1992, 97.2%
2, the harm of obesity, why we need to treat obesity
(1) affect the beauty of the body
(2) bring a lot of inconvenience to life
(3) huge medical expenses
(4) cause a variety of complications, shorten life expectancy: hyperlipidemia, gout, coronary heart disease, type 2 diabetes, hypertension, degenerative bone and joint changes, stroke, fatty liver, sleep apnea syndrome, gallstones, infertility, cancer, menstrual disorders, metabolic syndrome, bad fetus, etc.
Every year, the global obesity caused by 300,000 people died.
3.Surgical weight loss method: part of the serious obesity patients to control diet, exercise and drug treatment methods are not effective, surgical treatment is the most effective way to lose weight, but also the patient’s only choice at last.
4.Bariatric surgery
A, gastric septal bundle surgery: the most widely used weight loss surgery in 1980~2000
B. Laparoscopic gastric controlled banding surgery: It has gradually emerged in the past 10 years, replacing gastric septal banding, and is the standard bariatric surgery in Europe and Australia, becoming the most commonly performed bariatric surgery.
C, laparoscopic gastric bypass bariatric surgery: long history of good results, is the gold standard of obesity surgery in the United States
D.Laparoscopic pancreaticobiliary bypass surgery: still an effective surgery for super obese people
E. Laparoscopic tubular gastric reduction surgery: the latest bariatric surgery
Diabetes surgery treatment
Diabetes is a serious threat to human health metabolic diseases global incidence of diabetes is increasing year by year, especially prevalent in developing countries Chinese diabetes incidence: 0.67% in 1980, 9.7% in 2009, about 130 million people
According to the International Diabetes Federation (IDF) estimates, there will be 1.01 million new cases of diabetes in China each year, 2,767 new cases of diabetes each day, and 115 new cases of diabetes each hour.
However, the dilemma in the field of diabetes research: the low cure rate of diabetes and the lack of a long-term effective cure for diabetes .
In the 1950s, Professor Edward Mason of the University of Iowa, the father of bariatric surgery, found that obese patients lost significant weight after bariatric surgery, and the accompanying type 2 diabetes also improved to varying degrees.
In 2009, the American Diabetes Alliance (ADA) and The American Society of Metabolic and Bariatric Surgery recommended gastric diversion surgery as a treatment option for diabetes, even for mild to moderate obesity.
Our study shows that the regulation of glucose metabolism by gastrointestinal endocrine hormones after gastric diversion surgery is the main mechanism of surgical treatment of diabetes, namely the intestinal neuroendocrine doctrine – the surgery changes the flow of food, which enters the terminal small intestine earlier and induces the secretion of enteroglucagon (Incretin), which regulates islet endocrine function through the intestine-islet axis.
Recently in the United States, Europe and Brazil, surgery has begun to be recommended for the treatment of non-severely obese diabetic patients.
In the coming years, gastric diversion surgery will change the traditional treatment of diabetes, and we believe that as the research on the mechanism of gastric diversion surgery for the treatment of diabetes progresses, we will open up a new field of diabetes treatment, and this research will certainly benefit 190 million diabetic patients worldwide!
Gastric Diversion Surgery
Gastric Bypass Surgery – A Gospel for Diabetic Patients
What is Gastric Bypass Surgery
Gastric Bypass Surgery (GBP) originated from bariatric surgery and is a Billroth II-based GI reconstruction procedure that anastomoses the proximal gastric cavity with the small intestine, changing the physiological flow of food, hence the name GBP. Billroth performed the first residual gastric-jejunal anastomosis, followed by Cesar Roux at the University of Lausanne, Switzerland, who performed the first total gastrectomy followed by an esophago-jejunal anastomosis (Roux-en-Y procedure).
Surgery for diabetes – a surgeon’s clinical discovery
Edward Mason, now a retired University of Iowa surgeon, recalls: In the 1950s, we noticed an interesting phenomenon after GBP: obese patients with diabetes improved their blood glucose levels significantly after surgery, and even before they were discharged from the hospital, they no longer needed insulin.
It is no coincidence that one day in 1980, at East Carolina University School of Medicine, surgeon Walter Pories was performing GBP on his first obese patient with diabetes, followed by a second and a third operation… after which he found the same phenomenon as described by Mason: the patient no longer needed insulin after the operation. However, this did not concern Pories, and when confronted with the fourth patient, Pories thought there might be something wrong with the glucose meter, and he even angrily blamed the testers for the error, because the medical opinion at the time was that “diabetes was an incurable disease.
As the number of people cured of diabetes increased, Pories began to realize that the hypoglycemic effect of GBP was a true fact. However, the fact that the surgery treated diabetes was too overwhelming for him to even publish the findings, and Pories decided to continue to follow up on the control of his patients after the surgery. The cure rate for diabetes could be as high as 80% of cases (121/146), a result far superior to any medical treatment available at the time.
In 2003, Dr. Philip Schauer of the Cleveland Clinic in Ohio published a clinical follow-up study: 1160 Roux-en-Y GBP patients were followed up for 5 years after surgery, 191 of whom had diabetes, and 83% of them had normalized their glucose metabolism. The fact that GBP treats diabetes mellitus.
Mechanism of surgical treatment of diabetes mellitus
The pathogenesis of diabetes had long been the domain of internal medicine until the 1950s, when clinical discoveries in surgery broke the “quiet waters”. While surgeons in different hospitals were repeatedly verifying the authenticity of GBP for the treatment of diabetes, more scholars had begun to study the hypoglycemic mechanism of GBP, and this area of research had become a “hot” topic for researchers, resulting in many ideas and hypotheses.
Initially, it was thought that the hypoglycemic effect of GBP was related to weight loss in obese patients. Scopinaro et al. at the University of Genoa School of Medicine in Italy found that: within 10 days after GBP, the patient’s blood glucose level returned to normal and no significant weight loss had occurred; one month after GBP, the patient’s blood glucose level had returned to normal, but the body mass index still exceeded the normal standard by 80%; surgeon Francesco Rubino at Weill Cornell Medical College in New York Francesco Rubino, a surgeon at Weill Cornell Medical College in New York, performed GBP in non-obese rats and also obtained significant glucose-lowering effects similar to those in obese rats, indicating that weight loss was not related to the glucose-lowering effect. A clinical study at the General Hospital of the Armed Police in China found that 1 month after GBP, when the effect of weight loss was not yet obvious, the patient’s glucose tolerance had already improved significantly, so the above data suggest that there is no significant relationship between the recovery of blood glucose levels and weight loss after surgery.
The second view is that the glucose-lowering effect of GBP is related to the reduction in the amount of food eaten by patients after surgery. Those who hold this view believe that: (1) controlling diet and reducing caloric intake are essential components of a comprehensive diabetes treatment plan; and (2) vertical gastroplasty and adjustable gastric banding (AGB) can also improve the diabetic condition by restricting food intake alone. However, excessive food intake neither explains the pathogenesis of diabetes nor is it accompanied by obesity in all diabetic patients. Therefore, the current view is that postoperative food intake reduction is not the main mechanism for the treatment of diabetes with GBP for the following reasons: ① From the perspective of clinical studies, the bariatric surgery with the strongest effect of food intake restriction is not GBP but longitudinal bariatric surgery such as AGB, but the cure rate of type 2 diabetes after AGB (40%-47%) is significantly lower than that of GBP (83%), and in addition some patients after GBP In addition, the residual stomach can still be expanded and the amount of food intake can be gradually increased to near normal, which is part of the reason why some obese patients fail to lose weight after surgery; ② From the perspective of animal experimental studies, Rubino reported that the glucose tolerance of GK rats improved significantly after GBP surgery, and the area under the blood glucose curve decreased by about 40% or more; the sham-operated rats did not differ from the experimental rats in terms of surgery time, postoperative food intake and body weight values. The sham-operated rats did not differ from the experimental rats in terms of surgery time, postoperative food intake and body weight values, but the sham-operated rats did not show any improvement in blood glucose. A study in the General Hospital of the Chinese Armed Police showed that after GK rats underwent whole-gastric conversion surgery, their food intake was not significantly different from that of the control group, but their body weight increased, and their fasting glucose level and glucose tolerance improved significantly 4 weeks after surgery. Therefore, the hypoglycemic effect of GBP was not related to food intake or weight loss.
The unique feature of GBP is that it changes the physiological flow of food and divides the digestive tract into two parts according to whether food passes through or not: (i) food diversion zone – no food passes through the digestive tract, where endocrine hormone secretion in the digestive tract is reduced; (ii) food flow through zone – admission of incompletely digested food, where endocrine hormone secretion in the digestive tract increases.
Most scholars now believe that: the regulation of glucose metabolism by endocrine hormones in the gastrointestinal tract after GBP is one of the mechanisms of GBP for diabetes, i.e., the intestinal neuroendocrine theory – GBP surgery changes the flow of food through the intestinal-islet axis and regulates the endocrine function of the pancreas, suggesting that whether the stomach, duodenum, jejunum and ileum are exposed to food is related to the improvement of diabetes. The regulatory mechanism of the gut-islet axis is a complex biphasic one: positive regulation may come from a group of hormones with similar intestinal secretory function, including hormones such as cholecystokinin (CKK), GIP, glucagon-like peptide-1 (GLP-1) and ghrelin; negative regulation may come from lipid depots, including leptin and adiponectin, and may also from muscle tissue, as well as from hypothalamic regulatory mechanisms, which together constitute a complex set of feedback regulatory systems.
There are two hypotheses about the regulatory mechanism of the gut-islet axis: 1) hindgut hypothesis: food stimulation induces increased synthesis/secretion of gut-derived endocrine hormones, such as glucagon-like peptide-1 (GLP-1), which regulates islet endocrine function through the gut-islet axis, increases insulin synthesis and/or release, and improves insulin sensitivity in peripheral tissues. The physiological effects of GLP-1 include increasing insulin secretion, promoting islet proliferation and regeneration, and reducing islet apoptosis, and there are already commercialized diabetes drugs on the market, such as Byetta, a GLP-1 analogue that mimics the physiological effects of GLP-1 and has been proven to have definite efficacy in clinical trials and approved by the FDA. The foregut hypothesis is that nutrients avoid stimulation of the gastroduodenum and reduce the release of substances such as “islet resistance factor”, which suggests that diabetes is the result of overstimulation of the islets by one or more hormones produced in the foregut, just like gastrinoma. Zollinger-Ellison syndrome, and perhaps the presence of additional foregut endocrine hormones leading to hyperinsulinemia and subsequent insulin resistance, eventually leading to diabetes.
Currently, the changes in intestinal neuroendocrine function after GBP surgery have become a hot topic of research for scholars both nationally and internationally. Stephen Bloom of Royal University of London pointed out that the regulatory effect of GLP-1 on pancreatic tissue found in animal experiments is far from fully explaining the role of GLP-1 on human pancreatic tissue. In addition, the small intestine secretes numerous hormones, many of which we have studied very little, and we cannot yet exclude the regulatory role of other hormones, and this area is yet to be studied in depth.