Obesity Surgery

, 18:1035

A Comparison of a Personal Series of Biliopancreatic Diversion and Literature Data on Gastric Bypass Help to Explain the Mechanisms of Resolution of Type 2 Diabetes by the Two Operations

  • Nicola Scopinaro
  • Francesco Papadia
  • Giovanni Camerini
  • Giuseppe Marinari
  • Dario Civalleri
  • Adami Gian Franco
Opinion

Abstract

Background

Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD) are highly beneficial operations for type 2 diabetes mellitus (T2DM) in obese patients, leading to complete T2DM resolution in 75–90 and 97–99% of cases, respectively. In both RYGBP and BPD, the foregut is excluded from the food stream and the distal small bowel receives the food stimulation, while following BPD fat intestinal absorption is also extremely limited. This study was carried out to identify clinical features that could give insight on the different mechanisms of action on diabetes resolution.

Methods

The files of 443 severely obese patients with T2DM undergoing BPD from May 1976 to May 2007 were examined, and the presence of T2DM (fasting serum glucose >125 mg/ml) at 1–2 months, at 1 year, at 10 years, and at ≥20 years following the operation was recorded.

Results

The percentage of patients cured (fasting serum glucose reduced to ≤110 mg/dl, on free diet and with no therapy) was 74% at 1 month, 97% at 1 and 10 years, and 91% at ≥20 years, the 26% of uncured patients at 1 month being those with most severe preoperative T2DM.

Conclusions

As the early results after BPD resemble those reported after RYGBP, it can be hypothesized that the duodenal exclusion and the distal small bowel stimulation are the first mechanisms acting in BPD, immediately after the operation, that only subsequently the myocellular fat depletion, which cannot be immediate, takes over, and that the minimal fat absorption is the mechanism accounting for the long-term results of BPD.

Keywords

Morbid obesity Obesity surgery Biliopancreatic diversion Roux-en-Y gastric bypass Type 2 diabetes mellitus 

References

  1. 1.
    Scopinaro N, Marinari GM, Camerini GB, et al. Specific effects of biliopancreatic diversion on the major components of metabolic syndrome: a long-term follow-up study. Diabetes Care. 2005;28:2406–11.PubMedCrossRefGoogle Scholar
  2. 2.
    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–37.PubMedCrossRefGoogle Scholar
  3. 3.
    Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947–54.PubMedCrossRefGoogle Scholar
  4. 4.
    Adami GF, Cordera R, Camerini G, et al. Recovery of insulin sensitivity in obese patients at short term after biliopancreatic diversion. J Surg Res. 2003;113:217–21.PubMedCrossRefGoogle Scholar
  5. 5.
    MacDonald KG Jr, Long SD, Swanson MS, et al. The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg. 1997;1:213–20.PubMedCrossRefGoogle Scholar
  6. 6.
    Sugerman HJ, Wolfe LG, Sica DA, et al. Diabetes and hypertension in severe obesity and effects of gastric bypass-induced weight loss. Ann Surg. 2003;237:751–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339–52.PubMedCrossRefGoogle Scholar
  8. 8.
    Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238:467–84.PubMedGoogle Scholar
  9. 9.
    Torquati A, Lutfi R, Abumrad N, et al. Is Roux-en-Y gastric bypass surgery the most effective treatment for type 2 diabetes mellitus in morbidly obese patients? J Gastrointest Surg. 2005;9:1112–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Alexandrides TK, Skroubis G, Kalfarentzos F. Resolution of diabetes mellitus and metabolic syndrome following Roux-en-Y gastric bypass and a variant of biliopancreatic diversion in patients with morbid obesity. Obes Surg. 2007;17:176–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Rubino F, Gagner M. Potential of surgery for curing type 2 diabetes mellitus. Ann Surg. 2002;236:554–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Rubino F. Bariatric surgery: effects on glucose homeostasis. Curr Opin Clin Nutr Metab Care. 2006;9:497–507.PubMedCrossRefGoogle Scholar
  13. 13.
    Camastra S, Manco M, Mari A, et al. Beta-cell function in severely obese type 2 diabetic patients: long-term effects of bariatric surgery. Diabetes Care. 2007;30:1002–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Scopinaro N, Marinari GM, Pretolesi F, et al. Energy and nitrogen absorption after biliopancreatic diversion. Obes Surg. 2000;10:436–41.PubMedCrossRefGoogle Scholar
  15. 15.
    Sarson DL, Scopinaro N, Bloom SR. Gut hormone changes after jeunoileal or biliopancreatic bypass surgery for morbid obesity. Int J Obes. 1981;5:471–6.PubMedGoogle Scholar
  16. 16.
    Guidone C, Manco M, Valera-Mora E, et al. Mechanisms of recovery from type 2 diabetes after malabsorptive bariatric surgery. Diabetes. 2006;55:2025–31.PubMedCrossRefGoogle Scholar
  17. 17.
    Pories WJ, Albrecht RJ. Etiology of type II diabetes mellitus: role of the foregut. World J Surg. 2001;25:527–31.PubMedCrossRefGoogle Scholar
  18. 18.
    Rubino F, Marescaux J. Effect of duodenal-jejunal exclusion in a non-obese animal model of type 2 diabetes: a new perspective for an old disease. Ann Surg. 2004;239:1–11.PubMedCrossRefGoogle Scholar
  19. 19.
    Morinigo R, Lacy AM, Casamitjana R, et al. GLP-1 and changes in glucose tolerance following gastric bypass surgery in morbidly obese subjects. Obes Surg. 2006;16:1594–601.PubMedCrossRefGoogle Scholar
  20. 20.
    Whitson BA, Leslie DB, Kellogg TA, et al. Entero-endocrine changes after gastric bypass in diabetic and nondiabetic patients: a preliminary study. J Surg Res. 2007;141:31–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Laferrere B, Heshka S, Wang K, et al. Incretin levels and effect are markedly enhanced 1 month after Roux-en-Y gastric bypass surgery in obese patients with type 2 diabetes. Diabetes Care. 2007;30:1709–16.PubMedCrossRefGoogle Scholar
  22. 22.
    Greco AV, Mingrone G, Giancaterini A, et al. Insulin resistance in morbid obesity: reversal with intramyocellular fat depletion. Diabetes. 2002;51:144–51.PubMedCrossRefGoogle Scholar
  23. 23.
    Adami GF, Parodi RC, Papadia F, et al. Magnetic resonance spectroscopy facilitates assessment of intramyocellular lipid changes: a preliminary short-term study following biliopancreatic diversion. Obes Surg. 2005;15:1233–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg. 1998;22:936–46.PubMedCrossRefGoogle Scholar
  25. 25.
    Scopinaro N, Papadia F, Marinari G, et al. Long-term control of type 2 diabetes mellitus and the other major components of the metabolic syndrome after biliopancreatic diversion in patients with BMI < 35 g/m2. Obes Surg. 2007;17:185–92.PubMedCrossRefGoogle Scholar
  26. 26.
    Briatore L, Salani B, Andraghetti G, et al. Restoration of acute insulin response in T2DM subjects 1 month after biliopancreatic diversion. Obesity. 2008;16:77–81.PubMedCrossRefGoogle Scholar
  27. 27.
    Polyzogopoulou EV, Kalfarentzos F, Vagenakis AG, et al. Restoration of euglycemia and normal acute insulin response to glucose in obese subjects with type 2 diabetes following bariatric surgery. Diabetes. 2003;52:1098–103.PubMedCrossRefGoogle Scholar
  28. 28.
    Mari A, Manco M, Guidone C, et al. Restoration of normal glucose tolerance in severely obese patients after bilio-pancreatic diversion: role of insulin sensitivity and beta cell function. Diabetologia. 2006;49:2136–43.PubMedCrossRefGoogle Scholar
  29. 29.
    Muscelli E, Mingrone G, Camastra S, et al. Differential effect of weight loss on insulin resistance in surgically treated obese patients. Am J Med. 2005;118:51–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Ferrannini E, Camastra S, Gastaldelli A, et al. Beta-cell function in obesity: effects of weight loss. Diabetes. 2004;53 Suppl 3:S26–33.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2008

Authors and Affiliations

  • Nicola Scopinaro
    • 1
    • 2
  • Francesco Papadia
    • 1
  • Giovanni Camerini
    • 1
  • Giuseppe Marinari
    • 1
  • Dario Civalleri
    • 1
  • Adami Gian Franco
    • 1
  1. 1.Department of SurgeryUniversity of Genoa Medical School—Azienda Ospedaliera, Universitaria San MartinoGenoaItaly
  2. 2.Dipartimento di ChirurgiaAzienda Ospedaliera Universitaria San MartinoGenoaItaly

Personalised recommendations