From Bariatric to Metabolic Surgery: Definition of a New Discipline and Implications for Clinical Practice

Lipid and Metabolic Effects of Gastrointestinal Surgery (F Rubino, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Lipid and Metabolic Effects of Gastrointestinal Surgery

Abstract

Bariatric surgery indicates a variety of gastrointestinal (GI) surgical procedures originally designed to induce weight reduction in morbidly obese patients. Benefits of bariatric surgery, however, extend well beyond weight loss and include dramatic improvement of type 2 diabetes, hypertension, dyslipidemia, and reduction of overall mortality. Furthermore, studies in rodents and humans show that the anti-diabetes effect of certain bariatric procedures results from a variety of neuroendocrine and metabolic mechanisms secondary to changes in GI anatomy. The recognition that benefits and mechanisms of GI operations are not limited to weight reduction provided a rationale for the emergence of metabolic surgery intended as a surgical approach primarily aimed to the treatment of diabetes and metabolic disease. Consistent with the goals of improving glycemic and metabolic control, in contrast to mere weight loss, metabolic surgery implies the development of a new model of care distinct from traditional bariatric surgery. This paper discusses the definition of metabolic surgery and its clinical practice.

Keywords

Obesity Diabetes Metabolic surgery Bariatric surgery Gastric bypass Sleeve gastrectomy Gastric banding 

References

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  1. 1.
    Friedman MN, Sancetta AJ, Magovern GJ. The amelioration of diabetes mellitus following subtotal gastrectomy. Surg Gynecol Obstet. 1955;100(2):201–4.PubMedGoogle Scholar
  2. 2.
    Angervall L, Dotevall G, Tillander H. Amelioration of diabetes mellitus following gastric resection. Acta Med Scand. 1961;169:743–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Ahmad U, Danowski TS, Nolan S, Stephan T, Sunder JH, Bahl VK. Remissions of diabetes mellitus after weight reduction by jejunoileal bypass. Diabetes Care. 1978;1(3):158–65.PubMedCrossRefGoogle Scholar
  4. 4.
    Printen KJ, Blommers TJ, Scott D. The morbidly obese diabetic and gastric bypass. Am Surg. 1979;45(8):491–4.PubMedGoogle Scholar
  5. 5.
    Ackerman NB. Observations on the improvements in carbohydrate metabolism in diabetic and other morbidly obese patients after jejunoileal bypass. Surg Gynecol Obstet. 1981;152(5):581–6.PubMedGoogle Scholar
  6. 6.
    Pories WJ, Caro JF, Flickinger EG, Meelheim HD, Swanson MS. The control of diabetes mellitus (NIDDM) in the morbidly obese with the Greenville Gastric Bypass. Ann Surg. 1987;206(3):316–23.PubMedCrossRefGoogle Scholar
  7. 7.
    Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339–50. discussion 350-332.PubMedCrossRefGoogle Scholar
  8. 8.
    Scopinaro N, Adami GF, Marinari GM, Gianetta E, Traverso E, Friedman D, et al. Biliopancreatic diversion. World J Surg. 1998;22(9):936–46.PubMedCrossRefGoogle Scholar
  9. 9.
    Rubino F, Gagner M. Potential of surgery for curing type 2 diabetes mellitus. Ann Surg. 2002;236(5):554–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Rubino F, Gagner M, Gentileschi P, et al. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weight regulation and glucose metabolism. Ann Surg. 2004;240(2):236–42.PubMedCrossRefGoogle Scholar
  11. 11.
    Rubino F, Marescaux J. The 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):1–11.PubMedGoogle Scholar
  12. 12.
    Rubino F, Forgione A, Cummings DE, Vix M, Gnuli D, Mingrone G, 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
  13. 13.
    Troy S, Soty M, Ribeiro L, Laval L, Migrenne S, Fioramonti X, et al. Intestinal gluconeogenesis is a key factor for early metabolic changes after gastric bypass but not after gastric lap-band in mice. Cell Metab. 2008;8:201–11.PubMedCrossRefGoogle Scholar
  14. 14.
    Jiao J, Bae EJ, Bandyopadhyay G, Oliver J, Marathe C, Chen M, et al. Restoration of euglycemia after duodenal bypass surgery is reliant on central and peripheral inputs in Zucker fa/fa rats. Diabetes. 2013;62(4):1074–83. doi:10.2337/db12-068.PubMedCrossRefGoogle Scholar
  15. 15.
    Salinari S, Debard C, Bertuzzi A, Durand C, Zimmet P, Vidal H, et al. Jejunal proteins secreted by db/db mice or insulin-resistant humans impair the insulin signaling and determine insulin resistance. PLoS One. 2013;8(2):e56258. doi:10.1371/journal.pone.0056258.PubMedCrossRefGoogle Scholar
  16. 16.
    Laferrere B, Teixeira J, McGinty J, Tran H, Egger JR, Colarusso A, et al. Effect of weight loss by gastric bypass surgery versus hypocaloric diet on glucose and incretin levels in patients with type 2 diabetes. J Clin Endocrinol Metab. 2008;93:2479–85.PubMedCrossRefGoogle Scholar
  17. 17.
    Strader AD, Vahl TP, Jandacek RJ, Woods SC, D’Alessio DA, Seeley RJ. Weight loss through ileal transposition is accompanied by increased ileal hormone secretion and synthesis in rats. Am J Physiol Endocrinol Metab. 2005;288:E447–53.PubMedCrossRefGoogle Scholar
  18. 18.
    Pournaras DJ, Glicksman C, Vincent RP, Kuganolipava S, Alaghband-Zadeh J, Mahon D, et al. The role of bile after Roux-en-Y gastric bypass in promoting weight loss and improving glycaemic control. Endocrinology. 2012;153:3613–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Liou AP, Paziuk M, Luevano Jr JM, Machineni S, Turnbaugh PJ, Kaplan LM. Conserved shifts in the gut microbiota due to gastric bypass reduce host weight and adiposity. Sci Transl Med. 2013;5(178):178ra41.PubMedCrossRefGoogle Scholar
  20. 20.
    •• Breen DM, Rasmussen BA, Kokorovic A, Wang R, Cheung GW, Lam TK. Jejunal nutrient sensing is required for duodenal-jejunal bypass surgery to rapidly lower glucose concentrations in uncontrolled diabetes. Nat Med. 2012;18:950–5. This paper corroborates previous findings of weight-independent mechanisms of action of duodenal bypass surgery and shows how reduced glucose production in the liver, activated by intestinal nutrient sensing can play a role in the anti-diabetic effect of duodenal exclusion. Of note, this study also shows glucose lowering effect of duodenal bypass surgery also in rodent models of type 1 diabetes, therefore suggesting that insulin-independent GI mechanisms might be a plausible target for future treatments of type 1 and type 2 diabetes.PubMedCrossRefGoogle Scholar
  21. 21.
    Saeidi N, Meoli L, Nestoridi E, Gupta NK, Kvas S, Kucharczyk J, et al. Reprogramming of intestinal glucose metabolism and glycemic control in rats after gastric bypass. Science. 2013;341(6144):406–10.PubMedCrossRefGoogle Scholar
  22. 22.
    Cohen RV, Schiavon CA, Pinheiro JS, Correa JL, Rubino F. Duodenal-jejunal bypass for the treatment of type 2 diabetes in patients with body mass index of 22-34 kg/m2. Surg Obes Relat Dis. 2007;3:195–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Cohen RV, Pinheiro JC, Schiavon CA, Salles JE, Wajchenberg BL, Cummings DE. Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity. Diabetes Care. 2012;35:1420–8.PubMedCrossRefGoogle Scholar
  24. 24.
    •• Dixon JB, O’Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299:316–23. This is a RCT comparing LAGB vs medical treatment of type 2 diabetes in moderately and severely obese patients. The study shows that surgery achieves better glycemic control than medical therapy.PubMedCrossRefGoogle Scholar
  25. 25.
    •• Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Leccesi L, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366:1577–85. This is a RCT comparing two surgical procedures, RYGB and BPD, vs medical treatment of type 2 diabetes in severely obese patients. The study shows that both surgical procedures outperform medical therapy at 2-year after treatment initiation with approx. 80% of RYGB patients and >90% of BPD patients achieving remission of diabetes.PubMedCrossRefGoogle Scholar
  26. 26.
    •• Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567–76. This is a RCT comparing two surgical procedures, RYGB and sleeve gastrectomy, vs intensive medical treatment of type 2 diabetes in patients with BMI 30–40. The study shows that both surgical procedures achieve better glycemic control compared medical therapy at 1-year after treatment initiation, with 42% of RYGB patients achieving complete disease remission.PubMedCrossRefGoogle Scholar
  27. 27.
    •• Ikramuddin S, Korner J, Lee WJ, Connett JE, Inabnet WB, Billington CJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013;309(21):2240–9. This is a RCT comparing RYGB vs intensive medical treatment of type 2 diabetes in patients with BMI 30–40. The study shows that both RYGB achieves better glycemic/metabolic control than medical therapy at 1 year after treatment initiation.PubMedCrossRefGoogle Scholar
  28. 28.
    Sjöström L, Narbro K, Sjöström CD, et al. Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–52.PubMedCrossRefGoogle Scholar
  29. 29.
    •• Sjostrom L et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307:56–65. This study shows that patients undergoing bariatric surgery have lower rates of myocardial infarction and stroke compared to carefully matched group of patients who had usual treatment of obesity and diabetes.PubMedCrossRefGoogle Scholar
  30. 30.
    • Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122–31. This is a prospective study of 1156 severely obese patients comparing health outcomes of 3 groups of patients: one that sought and received RYGB surgery, one that sought but did not have surgery, and one where patients were randomly selected from a population-based sample not seeking weight loss surgery. The study shows that compared to non-surgical management, RYGB surgery is associated with higher rates of diabetes remission and lower risk of cardiovascular disease over 6 years.Google Scholar
  31. 31.
    Rubino R, Kaplan LM, Schauer PR, Cummings DE. 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
  32. 32.
    Buchwald H, Varco RL. Metabolic surgery. New York: Grunne and Stratton; 1978.Google Scholar
  33. 33.
    Fried M, Ribaric G, Buchwald JN, Svacina S, Dolezalova K, Scopinaro N. Metabolic surgery for the treatment of type 2 diabetes in patients with BMI <35 kg/m2: an integrative review of early studies. Obes Surg. 2010;20(6):776–90.PubMedCrossRefGoogle Scholar
  34. 34.
    Lee WJ, Hur KY, Lakadawala M, Kasama K, Wong SK, Lee YC. Gastrointestinal metabolic surgery for the treatment of diabetic patients: a multi-institutional international study. J Gastrointest Surg. 2012;16(1):45–51.PubMedCrossRefGoogle Scholar
  35. 35.
    Rubino F, Cummings DE. The coming of age of metabolic surgery. Nat Rev Endocrinol. 2012;8(12):702–4.PubMedCrossRefGoogle Scholar
  36. 36.
    Pratt GM, Learn CA, Hughes GD, Clark BL, Warthen M, Pories W. Demographics and outcomes at American Society for Metabolic and Bariatric Surgery Centers of Excellence. Surg Endosc. 2009;23(4):795–9.PubMedCrossRefGoogle Scholar
  37. 37.
    LABS Writing Group for the LABS Consortium, Belle SH, Chapman W, Courcoulas AP, et al. Relationship of body mass index with demographic and clinical characteristics in the Longitudinal Assessment of Bariatric Surgery (LABS). Surg Obes Relat Dis. 2008;4(4):474–80.PubMedCrossRefGoogle Scholar
  38. 38.
    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.PubMedCrossRefGoogle Scholar
  39. 39.
    Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303(3):235–41.PubMedCrossRefGoogle Scholar
  40. 40.
    Nguyen NT, Nguyen XM, Lane J, Wang P. Relationship between obesity and diabetes in a US adult population: findings from the National Health and Nutrition Examination Survey, 1999–2006. Obes Surg. 2011;21(3):351–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Libeton M, Dixon JB, Laurie C, O’Brien PE. Patient motivation for bariatric surgery: characteristics and impact on outcomes. Obes Surg. 2004;14:392–8.PubMedCrossRefGoogle Scholar
  42. 42.
    •• Rubino F, Shukla A, Pomp A, Moreira M, Ahn SM, Dakin G. Bariatric, metabolic and diabetes surgery: what’s in a name? Ann Surg. 2013. This study compares patients demographics in traditional bariatric surgery vs metabolic surgery; the study shows how the intent of treating metabolic disease, diabetes, results in the selection of a substantially different patient population, with obvious implications for clinical care.Google Scholar
  43. 43.
    Dixon JB, Zimmet P, Alberti KG, Rubino F, on behalf of the International Diabetes Federation Taskforce on Epidemiology and Prevention. Bariatric surgery: an IDF statement for obese type 2 diabetes. Diabet Med. 2011;28(6):628–42.PubMedCrossRefGoogle Scholar
  44. 44.
    WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157–63.CrossRefGoogle Scholar
  45. 45.
    Low S, Chin MC, Ma S, Heng D, Deurenberg-Yap M. Rationale for redefining obesity in Asians. Ann Acad Med Singap. 2009;38:66–9.PubMedGoogle Scholar
  46. 46.
    Stevens J, Truesdale KP, Katz EG, Cai J. Impact of body mass index on incident hypertension and diabetes in Chinese Asians, American Whites, and American Blacks: the People’s Republic of China Study and the Atherosclerosis Risk in Communities Study. Am J Epidemiol. 2008;167:1365–74.PubMedCrossRefGoogle Scholar
  47. 47.
    Pories WJ, Dohm LG, Mansfield CJ. Beyond the BMI: the search for better guidelines for bariatric surgery. Obesity (Silver Spring). 2010;18(5):865–71.CrossRefGoogle Scholar
  48. 48.
    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(4):467–84.PubMedGoogle Scholar
  49. 49.
    Kadera BE, Lum K, Grant J, Pryor AD, Portenier DD, DeMaria EJ. Remission of type 2 diabetes after Roux-en-Y gastric bypass is associated with greater weight loss. Surg Obes Relat Dis. 2009;5(3):305–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Pinkney JH, Johnson AB, Gale EA. The big fat bariatric bandwagon. Diabetologia. 2010;53(9):1815–22.PubMedCrossRefGoogle Scholar
  51. 51.
    Zhao Y, Encinosa W. Bariatric surgery utilization and outcomes in 1998 and 2004. Statistical brief #23. 2007. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb23.pdf.
  52. 52.
    Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery. 2007;142(4):621–32.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.King’s College LondonLondonUK
  2. 2.Catholic University of RomeRomeItaly

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