Ivaylo Tzvetkov, Krasimir Shopov, Jordan Birdanov, Ivan Jurukov,
Hospital Doverie, Sofia, Bulgaria
Background
• According to recent studies obese patients with type II diabetes who undergo bariatric surgery revert to normal blood glucose and insulin levels and develop a dramatic increase in insulin sensitivity.
• However, the mechanisms involved are unknown.
• The Bariatric procedures, which develop such a rapid decrease in blood glucose and insulin levels are the malabsortive procedures as gastric by pass, duodenal switch and bilio-pancreatic diversion.
• Laboratory studies with diabetic rats, which underwent bariatric procedures showed improved glucose tolerance and decreased fasting blood glucose.
• Type II diabetes continues to be associated with high rates of morbidity and mortality, leading to both financial and social burdens.
• Obese patients has normal blood glucose, glycosylated hemoglobin and insulin levels and fourfold increase in insulin sensitivity without continuation of diabetic medication 2 to 4 weeks after Bariatric surgery.
• Bariatric surgery is going to be more aggressive in the last five years and attempts to apply that kind of surgery even to patients with BMI of 30 kg/m2.
• Bariatric surgery for type 2 diabetes must be performed within accepted international and national guidelines. This requires appropriate assessment for the procedure and comprehensive and ongoing multidisciplinary care, patient education, follow-up and clinical audit, as well as safe and effective surgical procedures. National guidelines for bariatric surgery in people with type 2 diabetes and a BMI of 35 or more need to be developed and promulgated.
Table 1: The classification of weight category by BMI
| Classification | Principal cut-off points | Cut-off points for Asians |
| Normal range | 18.5 – 24.9 | 18.5 – 22.923.0 – 24.9 |
| Pre-obese | 25.0 – 29.9 | 25.0 – 27.427.5 – 29.9 |
| Obese class I | 30.0 – 34.9 | 30.0 – 32.432.5 – 34.9 |
| Obese class II | 35.0 – 39.9 | 35.0 – 37.437.5 – 39.9 |
| Obese class III | ≥40.0 | ≥40.0 |
Aim of the study
• The aim of the study is to reveal initial experience with Surgical Treatment of Type 2 Diabetes in patients with BMI over 35 kg/m.
• We tried to compare the effect of the main types of bariatric procedures: – restrictive as vertical gastroplasty by Champion technique and Sleeve gastrectomy – malabsortive procedures as Gastric by pass on Diabetes type II in those patients and influence of
surgery over the metabolic control of diabetes and its associated risk factors.
Material and Methods
• Two types of restrictive Bariatric surgical procedures were done:
– Vertical Gastroplasty by Champion technique
– Sleeve Gastrectomy
• The malabsortive procedure was Gastric antecolic Mason type by pass.
• All surgical procedures were done laparoscopically
– key hole surgery with short stay after operations and fast recovery.
• Selection of patients was done to following criteria:
– BMI over 35kg/m
– moderate or well controlled Diabetes type 2 with oral or on insulin therapy
– controlled co-morbidity as arterial hypertension, sleep apnea, reflux disease
– lack of alcohol abuse or severe mental disorders
– contraindications for general anesthesia
• 36 patients with Diabetes type 2 and Morbid Obesity
were included in the study.
• Preoperative assessment included:
– blood sugar control for 24 hours before surgery, the same control on 1st and 3rd week after surgery, follow up of blood sugar 3,6 and 12 months after Bariatric Surgery
• Preoperative assessment of glycosylated hemoglobin and insulin levels 2 weeks before surgery. Their values 6,12,36 and 48 months after surgery were also followed up.
Results
• About 26 patients had inadequate controlled Diabetes type 2 one month before surgery with mild raised values of blood sugar and HbA1c was between 8 and 11% in 14 of them.
• 21 patients were on Insulin therapy before surgery and the other 15 patients on oral treatment and diet.
• Insulin blood levels were raised in 28 patients before surgery.
• About 34 patients had 1 month before surgery poorly to controlled arterial hypertension.
• All 36 patients had reflux disease with mild symptoms as regurgitation and heart burning, 11 of them had also hiatal hernias type I found on preoperative upper endoscopy and barium X-rays investigations
• Sugar blood tests showed significantly drop off 1 week after surgery in 31 patients. They had results from 5,1 to 7,4 mmol/l
• The other 5 patients had sugar blood results from 7,0 to 8,5 mmol/l in the first postoperative week and only in 2 patients with Vertical Gastroplasty sugar blood levels remained between 6,5 to 7,2 mmol/l one year after surgery.
• The results of HbA1c dropped to 6,0- 7,0% in 2 to 3 months after surgery and remained on that levels in 33 patients 1 year after surgery.
• Insulin levels were normal in all patients 3 to 6 months after surgery.
• 34 patients did not need any medical treatment about Diabetes type 2 within 15 to 18 months after surgery.
• The other two patients were only on oral therapy and diet for treatment of Diabetes type 2.
• The blood pressure was normal in 27 patients 6 months after surgery. The other 9 patients reduced oral intake of medications for that co-
morbidity significantly (p> 0,05).
• About 14 patients had improvement of arterial blood supply of lower limbs 4 to 6 months after bariatric surgery done by doppler duplex scan.
• The quality of life in all patients was assessed by themselves with 8 to 10 points according to VAS 6 months to 1 year after surgery
Table 2: 2 & 4 year diabetes incudence and remission rates in our study
| Remission based on fasting plasma glucose <7.0 mmol/l and not on hypoglycaemic therapy |
After Bariatric Malabsortive Surgery | Control Group with Lap-Band and Vertical Gastroplasty |
| 2-year incident | 0,5 % | 2,5% |
| 4-year incident | 2,0% | 4,5% |
| 2-year remission | 92% | 68% |
| 4-years remission | 75% | 46% |
Conclusions
• Our data supports recent investigations and multi-central studies about recommendations for surgical treatment of morbid obese patients with BMI over 35kg/m2 and Dabetes type 2.
• Laparoscopic Bariatric surgery has a history of more than 15 years with good outcome and low rate of complications as in laparoscopic cholecystectomy.
• LRYGB procedures influence the gut hormonal milieu and provide an early non-weight related improvement in glycaemic control of type 2 diabetes according to our study.
• Diabetes type 2 remits or improves in the majority of patients after bariatric surgery. The procedures producing greater excess weight loss as Gastric bypass and Sleeve Gastrectomy lead to higher remission rates.
• We need a Bulgarian official survey and consent between surgeons and endocrinology specialists to establish national guidelines for treatment of
Morbid obese patients with Diabetes type 2.
• The societies of Bulgarian surgeons and endocrinology specialists have to make further steps to inform the society and Ministry of Health that surgical treatment of Diabetes type 2 is not a myth or an experiment with commercial issues as it was said a year ago by a representative of the National Health Insurance Fund but a medical based evidence for a new treatment option of Diabetes type 2 all over the world.
What is a successful outcome of bariatric surgery for a person with type 2 diabetes?
• HbA1c <6,0%
• No hypoglycaemia
• Total cholesterol < 4 mmol/l, LDL cholesterol < 2 mmol/l
• Triglycerides <2,2 mmol/l
• Blood pressure < 135/85 mmHg
• Over 15% weight loss
• With reduced medication from the pre-operated state or without other medications (where medications are continued, reduced doses from pre-surgery with minimal side effects would be expected)
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