Medical-Nutrition-Therapy for Obese Patients with Type 2 Diabetes Mellitus Undergoing Metabolic Surgery

Currently, metabolic surgery (Laparoscopic Roux-en-Y gastric bypass, LRYGB) has an important role and should be recommended as an intervention in the management of obese patients with type 2 diabetes mellitus (T2DM). A successful outcome of surgery requires medical nutrition therapy. Therefore, we performed a retrospective study on 25 patients with T2DM who underwent LRYGB at Yeouido St. Mary's Hospital from October 2008 to May 2010. The patients were followed up for an average of 6 months after surgery (range: 2~19 months). Diabetes was resolved in 80% of the patients. Percentage of excess weight loss was (%EWL) was 56.2%. After surgery, fasting blood sugar (FBS) and HbA1c were significantly reduced (123 mg/dl, A1c 6.7%, P<0.001) and triglyceride was also significantly reduced to 107.6 mg/dl (P<0.05). As diets of the patients progressed from liquid to soft to regular diet, energy, carbohydrates, and fat intakes increased significantly (P<0.001). But protein intake did not change significantly. Nutrient intake of the patients after the surgery was significantly lower than the recommended diet for the non-surgery group. Patients experienced side-effects related to the diets after surgery, including hair-loss (76%), smelly gas (52%), vomiting (48%), etc. A significantly positive correlation was observed between vomiting and FBS (P<0.001). There was a significant relationship between side effects and the amount of nutrient intakes. Therefore, guide patients to a diet progression with treatment to minimize side effects, especially vomiting. And monitor their dietary life to be healthy and not to regain weight until remission of T2DM.

The Impact of Metabolic and Bariatric Surgery on Morbidly Obese Patients with Type 2 DM

PURPOSE: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are the most effective intervention and cure in achieving sustained weight loss in the morbidly obese with co-morbities, especially in type 2 diabetes mellitus (DM). Currently, there are few data in the literature presenting early diabetic outcomes between the 2 major bariatric surgeries in Korea. The aim of this study is to observe weight loss, improvement of type 2 DM after LRYGB and LAGB. METHODS: 33 retrospective data were obtained from diabetic subjects undergoing LRYGB (n=53) and LAGB (n=77). These measurements included age, sex, body mass index (BMI), pre-operative diabetic duration, post-operative diabetic at follow-up visit after surgery. Paired t-test, and SPSS12.0 were used for statistical analysis. RESULTS: 33 morbidly obese patients with type 2 DM who had both procedures complain of general weakness. Most patients were taking oral medications or insulin and tired of them. Pre and post-op 12 months of percent of excess weight loss (%EWL), fetal bovine serum (FBS), hemoglobin A1c (HbA1C) presented at 0%, 185.6 mg/dl, 8.7% and 70.6%, 123.4 mg/dl, 6.6% in patients who had LRYGB (P<0.05). Pre and post-op 12 months of %EWL, FBS, HbA1C presented at 0%, 180.6 mg/dl, 8.4% and 32.8%, 136.5 mg/dl, 6.8% in patients who had LAGB (P<0.05). Rate of discontinuance or decreasing for treatment of type 2 DM after surgery showed 94% for LRYGB versus 80% for LAGB, and unchanged rates were 6% versus 20%, respectively. CONCLUSION: This study showed LRYGB and LAGB are quite satisfactory and promising bariatric procedures with significant weight loss and improvement of type 2 DM in Koreans. LRYGB is significantly associated with more weight loss, more diabetic outcome than LAGB. Clinical experiences in Korea with both procedures are limited and a larger number of cases are need, but the recent data shows promising results that are comparable to the international experience.

A Study on the Standards of Medical-Nutritional-Education by the Type of Bariatric Surgery in Morbid-obesity Patients

This study examined the effects of postoperative medical nutrition therapy on patients who had undergone bariatric surgery. Eighty seven patients who underwent bariatic-surgery at Yeouido St. Mary's Hospital from January 2007 to April 2009 were evaluated. The bariatric surgery patients included 42 Laparoscopic Roux-en Y gastric bypass (LRYGB) and 45 Laparoscopic adjustable gastric banding (LAGB) patients. Weight loss was more significant after LRYGB than after LAGB after 9 months (p<0.05). The LRYGB group was more satisfied with the weight loss (LRYGB 4.4/5.0, LAGB 3.0/5.0 p<0.001). The mean albumin, hemoglobin and hematocrit levels were significantly lower in the LRYGB group than in the LAGB group at the time of discharge (p<0.05~0.001). The GOT/GPT was significantly higher in the LRYGB group at the time of the operation than the LAGB group (p<0.01). The LRYGB group showed significantly lower intakes of total energy, carbohydrates, protein and fat from 1 week after surgery than the LAGB group. Multiple regression showed that the weight change after LRYGB was significantly more associated with the intakes of total energy at 1 week after surgery (p<0.01), SWS (sweets and high-calorie beverages) at 1 and 6 months after surgery (p<0.001), and fat at 3 months after surgery (p<0.01). In addition, LAGB was significantly more associated with the intakes of protein and NLS (non-liquid sweets) at 1 week after surgery (p<0.001, p<0.01), carbohydrate at 1 months after surgery (p<0.01), total energy at 3 months after surgery (p<0.001), HCL (high-calorie liquids) at 6 months after surgery (p<0.05), and fat at 9 months after surgery (p<0.01). These results suggest that continuous-follow-up medical nutrition therapy is needed according to the types of bariatric surgery, particularly during the weight loss phase (the first 1 week to 12 months).

Initial Experience with Bariatric Surgery in Korea: 120 Cases (LRYGB and LAGB) / 대한내시경복강경외과학회지

PURPOSE: Obesity has become a global epidemic disease, and bariatric surgery is now being increasingly performed in Korea as well as in western countries. Bariatric surgery has been performed in Korea since 2003. However, there is no data on cases of Korean bariatric surgery regarding the weight loss as well as the factors associated with the surgical outcome. METHODS: 120 total cases of bariatric surgery [LRYGB=48, LAGB=72] were done at St. Mary's Hospital. We retrospectively reviewed the series of bariatric cases and we analyzed the surgical outcome, the complications and the clinical factors associated with the surgical outcomes. RESULTS: There were no significant differences in age, BMI and pre-existing comorbidities for both procedures. The percentage of excess weight loss (%EWL) of the LRYGB at 6, 12 and 24 months was 63.8%, 73.7% and 87.5%, respectively, and the %EWL of the LAGB was 33.4%, 44.7% and 43.8%, respectively. Factors such age and gender were not associated with the surgical outcome. Yet the initial BMI tended to affect the surgical outcome. CONCLUSION: The results of our study indicate that LRYGB and LAGB are technically feasible and safe procedures. Both are quite satisfactory and promising procedures for loosing a significant amount of weight.

Laparoscopic Hiatal Hernia Repair during Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) / 대한내시경복강경외과학회지

Obesity is one of the most significant causes of GERD. Nissen fundoplication is a surgical procedure that's performed world widely for treating patients with GERD and a hiatal hernia and who are intractable to medical therapy. However, Nissen fundoplication may have technical difficulties in morbidly obese patients due to the huge perigastric, intraabdominal fat tissue and hepatomegaly. During the laparoscopic Roux-en-Y Gastric Bypass (LRYGB) procedure, the stomach was divided into the gastric pouch and the remnant stomach by vertiacally stapling at the angle of His. The posterior gastric wall and hiatus were easily exposed even when there was huge deposits of perigatric and intraabdominal fat tissue. We report here on a case of concomitant hiatal hernia repair with LRYGB in a morbidly obese patient.