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Obesity Surgery

, Volume 21, Issue 7, pp 889–895 | Cite as

Diabetes Remission and Insulin Secretion After Gastric Bypass in Patients with Body Mass Index <35 kg/m2

  • Wei-Jei Lee
  • Keong Chong
  • Chih-Yen Chen
  • Shu-Chun Chen
  • Yi-Chih Lee
  • Kong-Han Ser
  • Lee-Ming ChuangEmail author
Clinical Research

Abstract

Background

Most morbidly obese patients who undergo gastric bypass experience rapid remission of type 2 diabetes mellitus (T2DM) but the response in non-morbidly obese patients is not clear. This trial prospectively assessed the effect of diabetes remission, glucose metabolism, and the serial changes of insulin secretion after gastric bypass in inadequately controlled T2DM patients with a BMI of 23–35 kg/m2.

Methods

A total of 62 consecutive patients with T2DM and a BMI of 23–35 kg/m2 underwent gastric bypass. Data were prospectively collected before surgery and 1, 4, 12, 26, and 52 weeks and 2 years after surgery. Insulin secretion was measured by insulinogenic index and area under the curve (AUC) during a standard oral glucose tolerance test (OGTT). Remission of type 2 diabetes was defined as fasting glucose level <110 mg/dl and HbA1c <6.0% without any glycemic therapy.

Results

Of the 62 patients, 24 were men and 38 were women (age 43.1 ± 10.8 years). Their preoperative characteristics were as follows: BMI 30.1 ± 3.3 kg/m2, waist circumference 99.6 ± 9.6 cm, C-peptide 3.1 ± 1.4 ng/ml, and duration of T2DM 5.4 ± 5.1 years. The mean BMI decreased postoperatively to 22.6 ± 2.3 kg/m2 in 1 year and 23.0 ± 2.7 kg/m2 in 2 years. The mean HbA1c decreased from 9.7 ± 1.9% to 5.8 ± 0.5% in 1 year and 5.9 ± 0.5% in 2 years. Complete remission of T2DM was achieved in 57% in 1 year and 55% in 2 years after surgery. Before surgery, the OGTT test showed a blunted insulin secretion pattern with an insulinogenic index of 0.1 ± 0.2 and AUC of 2,324 ± 1,015 μIU min/ml. In 1 week after surgery, the insulinogenic index increased to 0.16 and AUC decreased to 1,366 μIU min/ml along with a rapid drop of insulin resistance. The insulinogenic index and AUC gradually increased to 0.27 and 3,220, respectively, 1 year after surgery and remained stable up to 2 years with a very low insulin resistance.

Conclusions

Laparoscopic gastric bypass facilitates immediate improvement in the glucose metabolism of inadequately controlled non-severe obese T2DM patients, and the benefit is sustained up to 2 years after surgery. The benefit is regulated by the decrease in insulin resistance, increase in early insulin response, and total insulin secretion to glucose load.

Keywords

Insulin secretion Type 2 diabetes Gastric bypass 

Notes

Acknowledgments

This work was supported by the intramural grants from Taipei Veterans General Hospitals (V99C1-068 and V99F-010 to C.Y.C. and W.J.L.), Taiwan.

References

  1. 1.
    Wild S, Roglic G, Green A, et al. Global prevalence of diabetes for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047–52.PubMedCrossRefGoogle Scholar
  2. 2.
    Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA. 2009;301:2129–40.PubMedCrossRefGoogle Scholar
  3. 3.
    Ramachandran A, Ma RC, Snehalatha C. Diabetes in Asia. Lancet. 2010;375:408–18.PubMedCrossRefGoogle Scholar
  4. 4.
    Chang HY, Hsu CC, Pan WH, et al. Gender differences in trends in diabetes prevalence from 1993 to 2008 in Taiwan. Diabetes Res Clin Pract. 2010;90:358–64.PubMedCrossRefGoogle Scholar
  5. 5.
    Yokoyama H, Yamada H, Okudaira M, et al. High incidence of diabetic nephropathy in early-onset Japanese NIDDDM patients. Diabetes Care. 1998;21:1080–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation provides to be the most effective therapy for adult onset diabetes mellitus. Ann Surg. 1995;222:339–52.PubMedCrossRefGoogle Scholar
  7. 7.
    Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. NEJM. 2004;351:2683–93.PubMedCrossRefGoogle Scholar
  8. 8.
    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–37.PubMedCrossRefGoogle Scholar
  9. 9.
    Dixon JB, O’Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299:316–23.PubMedCrossRefGoogle Scholar
  10. 10.
    Sjostrom L, Narbro K, Sjostrom D, et al. Effect of bariatric surgery on mortality in Swedish obese subjects. NEJM. 2007;357:741–52.PubMedCrossRefGoogle Scholar
  11. 11.
    Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. NEJM. 2007;2007(357):753–61.CrossRefGoogle Scholar
  12. 12.
    Cohen R, Pinheiro JS, Correa JL, et al. Laparoscopic Roux-en-Y gastric bypass for BMI < 35 kg/m2: a tailored approach. Surg Obes Relat Dis. 2006;2:401–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Depaula AL, Macedo ALV, Rassi N, et al. Laparoscopic treatment of type 2 diabetes mellitus for patients with a body mass index less than 35. Surg Endosc. 2007;22:706–16.CrossRefGoogle Scholar
  14. 14.
    Lee WJ, Wang W, Lee YC, et al. Effects of laparoscopic mini-gastric bypass for type 2 diabetes mellitus: comparison of BMI > 35 and <35 kg/m2. J Gastrointest Surg. 2008;12:945–52.PubMedCrossRefGoogle Scholar
  15. 15.
    Shah SS, Todkar JS, Shah PS, et al. Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m2. Surg Obes Relat Dis. 2010;6:332–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Thaler JP, Cummings DE. Minireview: hormonal and metabolic mechanism of diabetes remission after gastrointestinal surgery. Endocrinology. 2009;150(6):2518–25.PubMedCrossRefGoogle Scholar
  17. 17.
    Rubino F, Kaplan LM, Schauer PR, et al. The Diabetes Surgery Summit Consensus Conference: recommendations for the evaluation and use of gastrointestinal surgery to treat type 2 diabetes mellitus. Ann Surg. 2010;251:399–405.PubMedCrossRefGoogle Scholar
  18. 18.
    Matthews DR, Hosker JP, Rudensky AS, et al. Homeostasis model assessment: insulin resistance and B-cell function from fasting plasma glucose and insulin concentration in man. Diabetologia. 1985;28:412–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Seltzer HS, Allen EW, Herron Jr AL, et al. Insulin secretion in response to glycemic stimulus: relation of delayed initial release to carbohydrate intolerance in mild diabetes mellitus. J Clin Invest. 1967;46:323–35.PubMedCrossRefGoogle Scholar
  20. 20.
    Lee WJ, Yu PJ, Wang W, et al. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: a prospective randomized controlled clinical trial. Ann Surg. 2005;242:20–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Wang W, Wei PL, Lee WJ, et al. Short-term results of laparoscopic mini-gastric bypass. Obes Surg. 2005;15:648–54.PubMedCrossRefGoogle Scholar
  22. 22.
    Chiu CC, Lee WJ, Wang W, et al. Prevention of trocar-wound hernia in laparoscopic bariatric operations. Obes Surg. 2006;16:913–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Buse JB, Caprio S, Cefalu WT, et al. How do we define cure of diabetes? Diabetes Care. 2009;32:2133–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Morínigo R, Moizé V, Musri M, et al. GLP-1, PYY, hunger and satiety following gastric bypass surgery in morbidly obese subjects. J Clin Endocrinol Metab. 2006;91:1735–40.PubMedCrossRefGoogle Scholar
  25. 25.
    Laferrère 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
  26. 26.
    Koner J, Inabnet W, Febres G, et al. Prospective study of gut hormone and metabolic changes after adjustable gastric banding and Roux-en-Y gastric bypass. Int J Obes. 2009;33:786–93.CrossRefGoogle Scholar
  27. 27.
    Mingrone G, Castagneto-Gissey L. Mechanisms of early improvement/resolution of type 2 diabetes after bariatric surgery. Diab Metab. 2009;35:518–23.CrossRefGoogle Scholar
  28. 28.
    Pournaras DJ, Osbrone A, Hawkins S, et al. Remission of type 2 diabetes after gastric bypass and banding: mechanism and 2 year outcomes. Ann Surg. 2010;252:966–71.PubMedCrossRefGoogle Scholar
  29. 29.
    Lee WJ, Lee YC, Ser KH, et al. Improvement of insulin resistance after obesity surgery: a comparison of gastric banding and bypass procedures. Obes Surg. 2008;18:1119–25.PubMedCrossRefGoogle Scholar
  30. 30.
    Lee WJ, Ser KH, Chong K, et al. Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion. Surgery. 2010;147:664–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Iaconelli A, Gniuli D, Panunzi S, et al. Effects of bilio-pancreatic diversion on diabetes complications. Diabetes Care. 2011;34:1–6.CrossRefGoogle Scholar
  32. 32.
    Doar JW, Thompson ME, Wilde CE, et al. Influence of treatment with diet alone on oral glucose-tolerance test and plasma sugar and insulin levels in patients with maturity onset diabetes mellitus. Lancet. 1975;1(7919):1263–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Kelly DE, Wing R, Buonocore C. Relative effect soft calorie restriction and weight loss in non-insulin-dependent diabetes mellitus. J Clin Endocrinol Metab. 1993;77:1287–93.CrossRefGoogle Scholar
  34. 34.
    Halter JB, Pflung AE. Relationship of impaired insulin secretion during surgical stress to anesthesia and catecholamine release. J Clin Endocrinol Metab. 1980;51:1093–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Sirinek K, O’Dorisio TM, Hill D, et al. Hyperinsulinism, glucose-dependent insulinotropic polypeptide, and the enteroinsular axis in morbidly obese patients before and after gastric bypass. Surgery. 1986;100:781–7.PubMedGoogle Scholar
  36. 36.
    Service GJ, Thompson GB, Service FJ, et al. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric bypass surgery. NEJM. 2005;353:249–54.PubMedCrossRefGoogle Scholar
  37. 37.
    Cummings DE. Gastric bypass and nesidioblastosis—too much of a good thing for islet? NEJM. 2005;353:300–2.PubMedCrossRefGoogle Scholar
  38. 38.
    Le Roux CW, Borg C, Wallis K, et al. Gut hypertrophy after gastric bypass is associated with increased glucagons-like peptide 2 and intestinal crypt cell proliferation. Ann Surg. 2010;252:50–6.PubMedCrossRefGoogle Scholar
  39. 39.
    Hickey MS, Pories WJ, MacDonald Jr KG, et al. A new paradigm for type 2 diabetes mellitus. Could it be a disease of the foregut? Ann Surg. 1998;227:637–44.PubMedCrossRefGoogle Scholar
  40. 40.
    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
  41. 41.
    Rubino F, Forgione A, Cummings DE, et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg. 2006;244:741–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Lee WJ, Chong K, Ser KH, et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized trial. Arch Surg. 2011;146(2):204–9.Google Scholar
  43. 43.
    De Paula AL, Stival AR, Macedo A, et al. Prospective randomized controlled trial comparing 2 version of laparoscopic ileal interposition associated with sleeve gastrectomy for patients with type 2 diabetes with BMI 21–3435 kg/m2. Surg Obes Relat Dis. 2010;6:296–305.PubMedCrossRefGoogle Scholar
  44. 44.
    Zervos E, Agle SC, Warren AJ, et al. Amelioration of insulin requirement in patients undergoing duodenal bypass for reasons other than obesity implicates foregut factors in the pathophysiology of type II diabetes. J Am Coll Surg. 2010;210:564–74.PubMedCrossRefGoogle Scholar
  45. 45.
    Demaria EJ, Winegar DA, Pate VW, et al. Early postoperative outcomes of metabolic surgery to treat diabetes from sites participating in the ASMBS bariatric surgery center of excellence program as reported in the Bariatric Outcomes Longitudinal Database. Ann Surg. 2010;252:559–67.PubMedGoogle Scholar
  46. 46.
    DiGiorgi M, Rosen DJ, Choi JJ, et al. Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up. Surg Obes Relat Dis. 2010;6:249–53.PubMedCrossRefGoogle Scholar
  47. 47.
    Chikunguwo SM, Wolfe LG, Dodson P, et al. Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;6:254–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2011

Authors and Affiliations

  • Wei-Jei Lee
    • 1
  • Keong Chong
    • 2
  • Chih-Yen Chen
    • 3
    • 4
  • Shu-Chun Chen
    • 1
  • Yi-Chih Lee
    • 1
  • Kong-Han Ser
    • 1
  • Lee-Ming Chuang
    • 5
    Email author
  1. 1.Department of SurgeryMin-Sheng General HospitalTaoyuanTaiwan
  2. 2.Department of Internal MedicineMin-Sheng General HospitalTaoyuanTaiwan
  3. 3.Faculty of MedicineNational Yang-Ming University School of MedicineTaipeiTaiwan
  4. 4.Division of Gastroenterology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
  5. 5.Department of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan

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