Abstract
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 (HbA1c < 7%) without antidiabetic medication. HbA1c 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.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Ranganath LR (2008) The entero-insular axis: implications for human metabolism. Clin Chem Lab Med 46:43–56
Hickey MS, Pories WJ, MacDonald KG Jr, Cory KA, Dohm GL, Swanson MS, Israel RG, Barakat HA, Considine RV, Caro JF, Houmard JA (1998) A new paradigm for type 2 diabetes mellitus? Could it be a disease of the foregut? Ann Surg 227:637–644
Greenway SE, Greenway FL, Klein S (2002) Effects of obesity surgery on non–insulin-dependent diabetes mellitus. Arch Surg 137:1109–1117
Patriti A, Facchiano E, Sanna A, Gulla N, Donini A (2004) The enteroinsular axis and the recovery from type II diabetes after bariatric surgery. Obesity 14:840–848
Rubino F, Forgione A, Cummings DE, Vix M, Gnuli D, Mingrone G, Castagnet M, Marescaux J (2006) 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 244:741–749
Strader AD, Vahl TP, Jandacek RJ, Woods SC, D’Alessio DA, Seeley RJ (2005) Weight loss through ileal transposition is accompanied by increased ileal hormone secretion and synthesis in rats. Am J Physiol Endocrinol Metab 288:E447–E453
Patriti A, Facchiano E, Annetti C, Aisa MC, Galli F, Fanelli C, Donini A (2005) Early improvement of glucose tolerance after ileal transposition in a nonobese type 2 diabetes rat model. Obes Surg 15:1258–1264
DePaula AL, Macedo ALV, Rassi N, Machado CA, Schraibman V, Silva LQ, Halpern H (2008) Laparoscopic treatment of type 2 diabetes mellitus for patients with a body mass index less than 35. Surg Endosc 22:706–16
American Diabetes Association (2006) Standards of medical care in diabetes: position statement. Diabetes Care 29(Suppl 1):S4–S42
Parikh M, Ayoung-Chee P, Romanos E, Lewis N, Pachter HL, Fielding G, Ren C (2007) Comparison of rates of resolution of diabetes mellitus after gastric banding, gastric bypass, and bilipancreatic diversion. J Am Coll Surg 205:631–635
Gumbs AA, Modlin IM, Ballantyne GH (2005) Changes in insulin resistance following bariatric surgery: role of caloric restriction and weight loss. Obes Surg 15:462–473
Flatt PR (2007) Effective surgical treatment of obesity may be mediated by ablation of the lipogenic gut hormone gastric inhibitory polypeptide (GIP): evidence and clinical opportunity for development of new obesity-diabetes drugs? Diab Vasc Dis Res 4:151–153
Dolan K, Hatzifotis M, Newbury L (2004) A comparison of laparoscopic adjustable gastric banding and biliopancreatic diversion in superobesitiy. Obes Surg 14:165–169
Gerich JE (1998) The genetic basis of type 2 diabetes mellitus: impaired insulin secretion versus impaired insulin sensitivity. Endocrine Rev 19:491–503
Gault VA, Irwin N, Green BD, Mccluskey JT, Greer B, Bailey CJ, Harriott P, O’Harte, FPM, Flatt PR (2005) Chemical ablation of gastric inhibitory polypeptide receptor action by daily (Pro 3) GIP administration improves glucose tolerance and ameliorates insulin resistance and abnormalities of islet structure in obesity-related diabetes. Diabetes 54:2436–2446
Zhou H, Yamada Y, Tsukiyama K, Miyawaki K, Hosokawa M, Nagashima K, Toyoda K, Naitoh R, Mizunoya W, Fushiki T, Kadowaki T, Seino Y (2005) Gastric inhibitory polypeptide modulates adiposity and fat oxidation under diminished insulin action. Biochem Biophys Res Commun 335:937–942
Theodorakis MJ, Carlson O, Muller DC, Egan JM (2004) Elevated plasma glucose-dependent insulinotropic polypeptide associates with hyperinsulinemia in impaired glucose tolerance. Diabetes Care 27:1692–1698
Cryer PE (2002) Hypoglycaemia: the limiting factor in the glycaemic management in type 1 and type 2 diabetes. Diabetologia 45:937–948
UK Prospective Diabetes Study (UKPDS) Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complication in patients with type 2 diabetes (UKPDS 33). Lancet 352:837–853
DePaula AL, Macedo ALV, Rassi N, Vencio S, Machado CA, Mota BR, Silva LQ, Halpern A, Schraibman V (2008) Laparoscopic treatment of metabolic syndrome in patients with type 2 diabetes mellitus. Surg Endosc [Epub ahead of print]
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
DePaula, A.L., Macedo, A.L.V., Mota, B.R. et al. 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. Surg Endosc 23, 1313–1320 (2009). https://doi.org/10.1007/s00464-008-0156-x
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-008-0156-x