Hormonal evaluation following laparoscopic treatment of type 2 diabetes mellitus patients with BMI 20-34.

BACKGROUND: A group of patients with type 2 diabetes mellitus (T2DM) and body mass index (BMI) 20-34 kg/m(2) were submitted to laparoscopic interposition of a segment of ileum into the proximal jejunum or into the proximal duodenum associated to a sleeve gastrectomy. The objective of this study is to evaluate the hormonal changes in the pre- and postoperative period. MATERIALS AND METHODS: Hormonal evaluation was done in 58 patients operated between April 2005 and July 2006. Mean age was 51.4 years (40-66 years). Mean BMI was 28.2 (20-34.8) kg/m(2). All patients had had the diagnosis of T2DM for at least 3 years. Mean duration of T2DM was 9.6 years (3-22 years). Two techniques were performed, consisting of different combinations of ileal interposition (II) associated to a sleeve gastrectomy (SG). The following hormones were assayed in the pre- and postoperative period (mean 16 months) at the baseline and following specific food stimulation (30, 60, 120 min): glucogen-like protein 1 (GLP-1), glucose-dependent insulinotropic peptide (GIP), insulin, glucagon, C-peptide, amylin, cholecystokinin (CCK), pancreatic polypeptide (PPP), somatostatin, peptide YY (PYY), ghrelin, adiponectin, resistin, leptin, and interleukin-6 (IL-6). RESULTS: Thirty patients had II associated to sleeve gastrectomy (II-SG) and 28 had II with diverted sleeve gastrectomy (II-DSG). GLP1 exhibited an important rise following the two operations, especially after II-DSG (p < 0.001). GIP also exhibited an important rise, with both II-SG and II-DSG being equally effective (p < 0.001). Insulin and amylin showed a significant rise at 30 min. Glucagon decreased slightly. CCK measurements were very low after II-DSG. PPP was also slightly altered by the II-DSG. PYY showed an important increase with both operations (p < 0.001). Ghrelin showed a significant decrease following the two operations (p < 0.001). Somatostatin and IL-6 were not affected (p = 0.632). Both leptin and resistin blood levels decreased. Adiponectin showed a slight increase. Mean postoperative follow-up was 19.2 months. Both II-SG and II-DSG were effective in achieving adequate glycemic control (91.2%). CONCLUSIONS: There was a significant hormonal change following laparoscopic ileal interposition. These alterations may explain the promising good results associated to these operations for the treatment of T2DM in the nonmorbidly obese population.

Laparoscopic ileal interposition associated to a diverted sleeve gastrectomy is an effective operation for the treatment of type 2 diabetes mellitus patients with BMI 21-29.

BACKGROUND: The objective of this study is to evaluate the clinical results of the laparoscopic interposition of a segment of ileum into the proximal duodenum associated to a sleeve gastrectomy (II-DSG) in order to treat patients with type 2 diabetes mellitus (T2DM) and body mass index (BMI) 21-29 kg/m2. PATIENTS AND METHODS: The laparoscopic procedure was performed in 69 patients, 22 female and 47 male. Mean age was 51 years (range 41-63 years). Mean BMI was 25.7 (21.8-29.2) kg/m2. All patients had the diagnosis of T2DM for at least 3 years and evidence of stable treatment with oral hypoglycemic agents and or insulin for at least 12 months. Insulin therapy was used by 44% of the patients. Mean duration of T2DM was 11 years (range 3-18 years). Dyslipidemia was diagnosed in 72.5% and hypertension in 66.7%. Nephropathy was characterized in 29% of the patients, retinopathy in 26.1%, and neuropathy in 24.6%. RESULTS: Overall, 95.7% of the patients achieved adequate glycemic control (Hb(A1c) < 7%) without antidiabetic medication. Hb(A1c) below 6% was achieved by 65.2%. Mean postoperative follow-up was 21.7 months (range 7-42 months). Mean postoperative BMI was 21.8 kg/m2. There was no conversion to open surgery. Median hospital stay was 3.4 days (range 2-58 days). Major postoperative complications were diagnosed in 7.3%. There was no mortality. Fasting glycemia decreased from a mean of 218 to 102 mg/dl, postprandial glycemia from 305 to 141 mg/dl, and homeostasis model assessment of insulin resistance (Homa-IR) from 5.2 to 0.77. All associated comorbidities and complications related to T2DM had significant improvement or control. Arterial hypertension was controlled in 91.3%. Macroalbuminuria was no longer observed. Microalbuminuria resolved in 87.5% of patients. Hypercholesterolemia was normalized in 95% and hypertriglyceridemia in 92% of patients. CONCLUSIONS: Laparoscopic II-DSG was an effective operation in controlling T2DM in a nonobese (BM < 30 kg/m2) population. Associated diseases and related complications were also improved. A longer follow-up period is needed.

Laparoscopic treatment of metabolic syndrome in patients with type 2 diabetes mellitus.

BACKGROUND: Metabolic syndrome refers to risk factors for cardiovascular disease. Hyperglycemia is a critical component contributing to the predictive power of the syndrome. This study aimed to evaluate the results from the laparoscopic interposition of an ileum segment into the proximal jejunum for the treatment of metabolic syndrome in patients with type 2 diabetes mellitus and a body mass index (BMI) lower than 35. METHODS: Laparoscopic procedures were performed for 60 patients (24 women and 36 men) with a mean age of 51.7 +/- 6.4 years (range, 27-66 years) and a mean BMI of 30.1 +/- 2.7 (range, 23.6-34.4). All the patients had a diagnosis of type 2 diabetes mellitus (T2DM) given at least 3 years previously and evidence of stable treatment using oral hypoglycemic agents, insulin, or both for at least 12 months. The mean duration of type 2 diabetes mellitus was 9.6 +/- 4.6 years (range, 3-22 years). Metabolic syndrome was diagnosed for all 60 patients. Arterial hypertension was diagnosed for 70% of the patients (mean number of drugs, 1.6) and hypertriglyceridemia for 70%. High-density lipoprotein was altered in 51.7% of the patients and the abdominal circumference in 68.3%. Two techniques were performed: ileal interposition (II) into the proximal jejunum and sleeve gastrectomy (II-SG) or ileal interposition associated with a diverted sleeve gastrectomy (II-DSG). RESULTS: The II-SG procedure was performed for 32 patients and the II-DSG procedure for 28 patients. The mean postoperative follow-up period was 7.4 months (range, 3-19 months). The mean BMI was 23.8 +/- 4.1 kg/m(2), and 52 patients (86.7%) achieved adequate glycemic control. Hypertriglyceridemia was normalized for 81.7% of the patients. An high-density lipoprotein level higher than 40 for the men and higher than 50 for the women was achieved by 90.3% of the patients. The abdominal circumference reached was less than 102 cm for the men and 88 cm for the women. Arterial hypertension was controlled in 90.5% of the patients. For the control of metabolic syndrome, II-DSG was the more effective procedure. CONCLUSIONS: Laparoscopic II-SG and II-DSG seem to be promising procedures for the control of the metabolic syndrome and type 2 diabetes mellitus. A longer follow-up period is needed.

Laparoscopic treatment of type 2 diabetes mellitus for patients with a body mass index less than 35.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a common disease with numerous complications. Bariatric surgery is an efficient procedure for controlling T2DM in morbidly obese patients. In T2DM, the incretin effect is either greatly impaired or absent. This study aimed to evaluate the preliminary results from interposing a segment of ileum into the proximal jejunum associated with a sleeve or diverted sleeve gastrectomy to control T2DM in patients with a body mass index (BMI) less than 35 kg/m(2). METHODS: For this study, 39 patients (16 women and 23 men) underwent two laparoscopic procedures comprising different combinations of ileal interposition into the proximal jejunum via a sleeve or diverted sleeve gastrectomy. The mean age of these patients was 50.3 years (range, 36-66 years). The mean BMI was 30.1 kg/m(2) (range, 23.4-34.9 kg/m(2)). All the patients had a diagnosis of T2DM that had persisted for at least 3 years and evidence of stable treatment with oral hypoglycemic agents or insulin for at least 12 months. The mean duration of T2DM was 9.3 years (range, 3-22 years). RESULTS: The mean operative time was 185 min, and the median hospital stay was 4.3 days. Four major complications occurred in the short term (30-days), and the mortality rate was 2.6%. The mean postoperative follow-up period was 7 months (range, 4-16 months), and the mean percentage of weight loss was 22%. The mean postoperative BMI was 24.9 kg/m(2) (range, 18.9-31.7 kg/m(2)). An adequate glycemic control was achieved for 86.9% of the patients, and 13.1% had important improvement. The patients whose glycemia was not normalized were using a single oral hypoglycemic agent. No patient needed insulin therapy postoperatively. All the patients except experienced normalization of their cholesterol levels. Targeted triglycerides levels were achieved by 71% of the patients, and hypertension was controlled for 95.8%. CONCLUSIONS: The laparoscopic ileal interposition via either a sleeve gastrectomy or diverted sleeve gastrectomy seems to be a promising procedure for the control of T2DM and the metabolic syndrome. A longer follow-up period is needed.