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Surgical Treatment For Type 2 Diabetes

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Assessing Efficacy And Safety

Bariatric surgery – Type 2 diabetes and treatment

Efficacy and safety should be assessed at least monthly for the first 3 months of treatment. If a patients response is deemed insufficient after 3 months or if there are significant safety or tolerability issues at any time, the medication should be discontinued and alternative medications or treatment approaches should be considered.

How To Perform A Pancreas Transplant

Over 40 different modifications of pancreas transplantation have been described but most are of historical interest.The graft is placed within the peritoneal cavity and revascularised to the external iliac artery and vein. One of the non-physiological consequences of this technique is that insulin is secreted into the systemic venous circulation. Portal venous drainage has been described and is favoured by some in order to avoid the potential atherogenic affects of peripheral hyperinsulinaemia. It is also more physiological in that it delivers insulin directly to its main target organ, the liver. However, this is technically more difficult and there is an appreciable risk of portal venous thrombosis.

Exocrine secretions are essentially managed in three different ways: either drainage into the bladder or small intestine, and although not commonly used outside France, duct obliteration by injection with a sclerosant. The advantages of bladder drainage are that a decline in urinary amylase allows the earlier detection of acute graft rejection. Another important consideration is that up to 25% of all pancreas transplants performed with bladder drainage will need enteric conversion at a later date. The reasons for this are metabolic acidosis, recurrent urinary tract infections, bladder mucosal dysplasia, and reflux pancreatitis and consequently enteric drainage is rapidly regaining popularity.

Diabetes Remission And Medications

As shown in , no participants in the LWLI treatment arm experienced either partial or complete remission of T2DM at 12 months. For the surgical treatment arms, 12 of 24 undergoing RYGB were classified with partial T2DM remission at 12 months and 4 with complete remission, as compared to 6 of 22 and 5 of those undergoing LAGB, respectively p=.0005, p=.047. Pairwise treatment comparisons were significant for RYGB vs. LWLI for partial T2DM remission and for both partial and complete remission for LAGB vs. LWLI . As shown in , there were significant reductions in diabetes medication usage at 12 months for both RYGB and LAGB compared to LWLI though no LAGB ) participant on insulin at baseline was discontinued at 12 months. There were significant treatment differences for glycemic control at 12 months with RYGB vs. LWLI and LAGB vs. LWLI for FPG change and RYGB vs. LAGB and RYGB vs. LWLI for change in glycated hemoglobin. For the LWLI group, there were no significant improvements over the 12 month period in either FPG or glycated hemoglobin.

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When Should You Contact Your Healthcare Provider If You Have Had Weight

In the short term, your healthcare team will provide a list of when you should contact the doctor, such as if you:

In the long term, while surgery is helpful in treating diabetes and sleep apnea, it will work best over time if you follow directions about eating, taking vitamins, and exercising. If you develop grazing habits , you may gain weight .

It is also important to pay attention to other habits that could be problems, like drinking too much, smoking, or using opioids. You should make sure to talk to your healthcare provider if you have thoughts of suicide.

Our Approach To Metabolic And Diabetes Surgery

Surgical Treatment for Type 2 Diabetes

Many patients turn to metabolic surgery also known as diabetes surgery when medication, a healthier diet, and lifestyle changes fail to keep their diabetes under control.

At Weill Cornell Medicine, individuals interested in surgery meet directly with surgeons to discuss their health goals and to learn more about available procedures.

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Surgical Treatment Of Type 2 Diabetes

With a prevalence of 58%, type 2 diabetes is one of the most common metabolic disorders in Germany. Chronic hyperglycemia goes hand in hand with an increased risk for microvascular complications, such as diabetic retinopathy, neuropathy, and nephropathy. This makes type 2 diabetes one of the most common causes of loss of eyesight, renal failure, and amputation of the lower limb . Diabetic nephropathy is the most common complication of type 2 diabetes and results in a substantially impaired quality of life for those affected. It also incurs high costs to the healthcare systemowing to expensive dialysis therapy, among others .

In addition to age, familial predisposition, and certain lifestyle factors, overweight is one of the factors promoting the manifestation of type 2 diabetes. Weight loss can help to delay the manifestation of type 2 diabetes, and weight reducing measures constitute basic treatment in patients with type 2 diabetes. Individually agreed therapeutic goals are, however, rarely achieved by means of basic therapy alone the guideline conform standard in this setting is stepwise escalation of pharmacotherapy for type 2 diabetes .

Metabolic surgery and diabetic nephropathy

Indication for surgical treatment in type 2 diabetes

Risks

  • Deficiencies in certain micronutrients,
  • increased suicidality.

Corresponding author:Prof. Dr. med. Matthias Blüher

Department für Innere Medizin

Safety Of Bariatric/metabolic Surgery

Procedures used in bariatric/metabolic surgery are characterized by distinct anatomic rearrangements . This implies differences in technical complexity, mechanisms of action, clinical outcomes, and safety profiles. Safety of bariatric/metabolic surgery also varies across hospitals and surgeons. Empirical data suggest that proficiency of the operating surgeon is an important factor determining mortality, complications, reoperations, and readmissions .

Safety of bariatric/metabolic surgery in general has improved significantly over the last two decades, with continued refinement of minimally invasive approaches , enhanced training and credentialing, and involvement of multidisciplinary teams. Mortality rates with bariatric/metabolic operations are typically 0.10.5%, similar to cholecystectomy or hysterectomy . Morbidity has also dramatically declined with laparoscopic approaches. Major complications rates are 26%, with minor complications in up to 15% , comparing favorably with other commonly performed elective operations .

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Who Is Eligible For Weight

  • You are more than 100 lbs. over your ideal body weight.
  • You have a Body Mass Index of over 40.
  • You have a BMI of over 35 and are experiencing severe negative health effects, such as high blood pressure or diabetes, related to being severely overweight.
  • You cannot achieve a healthy body weight for a sustained period of time, even through medically-supervised dieting.

For bariatric surgery to treat diabetes:

  • If you have a BMI of 35 or more with type 2 diabetes and/or other illnesses related to excess weight, and have not been able to achieve normal fasting blood sugar , you probably are a candidate for diabetes surgery.
  • In some cases of inadequately controlled diabetes, patients may be eligible for bariatric surgery even if they have a BMI of less than 35.

Nonsteroidal Mineralocorticoid Receptor Antagonists

Surgical and Medical Treatments for Type 2 Diabetes

In July 2021, the FDA approved finerenone for inhibition of the effects in adults of chronic kidney disease associated with type 2 diabetes, including sustained estimated glomerular filtration rate decline, end-stage kidney disease, cardiovascular death, nonfatal myocardial infarction, and hospitalization for heart failure. It is the first nonsteroidal mineralocorticoid receptor antagonist to be approved for this purpose. Approval was based on the FIDELIO-DKD trial, a placebo-controlled study that involved over 5700 patients with type 2 diabetes to whom the maximum-tolerated dose of renin-angiotensin system inhibitor was already being administered. However, until more data on finerenone is gathered, RASIs and SGLT-2 inhibitors will be the preferred agents for slowing chronic kidney disease in type 2 diabetes.

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What Is Type Two Disease & What Are The Symptoms

Type 2 diabetes is a common health condition that causes blood sugar levels in the body to become dangerously high. Patients with type 2 diabetes, often rely on anti-diabetic medication or insulin in order to control their blood sugar levels. Its important to understand the symptoms of type 2 diabetes and be on the look out for them especially if youre overweight, or diabetes runs in your family.

Symptoms of type 2 diabetes include:

  • Needing to use the restroom frequently or a lot more than usual
  • Having an increased thirst
  • Numb or tingling pain in the hands or feet, or both
  • Patches of dark skin

You might be suffering with type 2 diabetes if you experience one or more of these symptoms, however its not a forgone conclusion. Having symptoms related to diabetes does not necessarily mean you have the condition. You should speak to your doctor or healthcare provider to determine whether you have it or not. Moreover, acting fast can save lives and prevent the negative side effects of this illness.

Data Synthesis And Statistical Analysis

All data were analyzed using Review Manager version 5.3 for Mac. RR along with 95% CI was calculated for dichotomous data, and MD along with 95% CI was calculated for continuous data. The mean change of the included studies from baseline to end of follow-up was calculated. Missing standard deviations were derived from other statistics, such as P values or confidence intervals if needed . For example, P = 0.00001 was assumed when a P value was reported as P< 0.00001. When only a range was reported, a formula was used to estimate Standard deviation : Estimate SD = Range/4 Range/6 , and median was approximately equal to mean . Heterogeneity among combined study results was assessed by Cochrans Q test and by the degree of inconsistency . A random effect model was used if P < 0.05 and I2> 50%. Otherwise, data were pooled by using the fixed effect model . In the integration results, P< 0.05 indicated statistical significance. Publication bias in outcomes was assessed and treated using standard methodology. Publication bias was analyzed using a funnel plot.

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Scientific Research Explores Weight Loss Surgery & Diabetes

Metabolic and bariatric surgery is effective diabetes treatment. The current success rate associated with changes in lifestyle and drug therapies for treating type 2 diabetes is not very good. In fact, a recent study of about 5,000 patients showed that only 52% of patients achieved A1C less than 7 with lifestyle changes and drug therapy. Multiple studies compared medical treatment versus surgical resolution for type 2 diabetes. The surgical groups in every study had a very high rate of remission! The medical group had a very low, to no, rate of remission. Further investigation shows that patients who chose to have weight loss surgery maintained their weight loss and improved their quality of life.

A medical study found that 50-80% of patients with type 2 diabetes, who had weight loss surgery had a reduced risk of mortality. This study compared two groups of diabetes patients:

  • Those who choose to have weight-loss surgery.
  • Patients who opted for a non-surgical treatment such as exercise and dieting.

The results of the study found that for many patients with type 2 diabetes, surgery was a good option.

Information Sources And Search Strategy

Surgical Treatment for Type 2 Diabetes

We performed a comprehensive search in PubMed, Embase and Cochrane Library databases to identify all relevant studies available from their inception to June 15th 2016. We also searched trial registries of ongoing trials.

The search strategy followed the identification and screening guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search terms included and and . These terms were used in different Boolean combinations. Limits set to govern the searches stipulated journal articles on adult humans written in the English language. All eligible studies were retrieved, and the reference lists of the identified studies and reviews were evaluated or additional studies.

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Why Doctors For Diabetics Now Recommend Surgery Instead Of Drugs

New guidelines for surgical treatment of type 2 diabetes bolster hopes of finding a cure, according to Francesco Rubino, but long-standing preconceptions must be put aside

Clinical guidelines published this week announce what may be the most radical change in the treatment of type 2 diabetes for almost a century. Appearing in Diabetes Care, a journal of the American Diabetes Association, and endorsed by 45 professional societies around the world, the guidelines propose that surgery involving the manipulation of the stomach or intestine be considered as a standard treatment option for appropriate candidates. This development follows multiple clinical trials showing that gastrointestinal surgery can improve blood-sugar levels more effectively than any lifestyle or pharmaceutical intervention, and even lead to long-term remission of the disease.

Indications For Bariatric Surgery In Adolescents

Surgery should be considered if adolescents had BMI > 40 kg/m2, or > 35 kg/m2 with severe co-morbidities, including type 2 diabetes mellitus, aged > 15 years, with Tanner pubertal stage 4 or 5 and skeletal maturity, and could provide informed consent and patients have failed a lifestyle and pharmacotherapy for six months . International Diabetes Federation position statement advised that only two procedures Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are currently conventional bariatric surgical procedures for adolescents .

Type 2 diabetes mellitus and BMI > 35kg/m 2 Type 2 diabetes mellitus and BMI > 30, < 35 kg/m 2 Type 2 diabetes mellitus and BMI < 30 kg/m 2
IDF 2011

Current recommendations for surgical treatment in type 2 diabetes

Contraindications for bariatric surgery in the treatment of type 2 diabetes mellitus are: secondary diabetes, pancreatic autoantibodies positivity, C-peptide < 1ng/ml or unresponsive to mixed meal challenge.

The assessment of bariatric surgery outcomes in type 2 diabetes and factors indicating the beneficial effects of bariatric surgery in diabetes: There is not an international consensus regarding definition of success of bariatric surgery in diabetes mellitus.

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Type 2 Diabetes Surgery

Type 2 diabetes surgery is a surgical operation that enables the hormones to act, which ensures that the patient’s insulin level is at the correct levels. Two techniques are applied in type 2 diabetes surgeries. Illegal interposition and transit bipartition. In both of these surgeries, the main goal is to regulate the hormonal balance by surgical touches in the stomach and intestines. Type 2 diabetes surgeries are operations performed in a closed system . In the abdominal region, 5 or 6 1-inch-diameter incisions are opened and access to the abdominal region is made with surgical devices and cameras. This surgical intervention takes about 2 hours. People who have type 2 diabetes surgery are under observation in the hospital for 3-5 days, after hospitalization, they need to rest for about 5 more days. Since these surgeries are performed with laparoscopic technique, recovery time is very short. On the 10th postoperative day, people can return to their social lives.

What Are The Types Of Weight

Surgery for type 2 diabetes

Laparoscopic Roux-en-Y Gastric

How it works: This procedure involves creating a small stomach pouch. This reduces the amount of food you can eat. The intestine is connected to the new pouch and rerouted. The pouch is connected directly to the lower part of the small intestine. Food bypasses the lower stomach, the first part of the small intestine and some of the second part . The changes created during gastric bypass cause changes in the way the gut and the pancreas interact. This affects diabetes control even before weight is lost. Patients generally can return to work within three to four weeks. Gastric bypass is a good surgical option in many patients.

Laparoscopic Sleeve Gastrectomy

How it works: LSG reduces the size of the stomach and limits food intake. LSG is technically easier to perform than gastric bypass and is a good surgical option in many patients. Patients who are at risk for undergoing anesthesia, or who have a heart or lung problem and should not undergo a long surgery, may also benefit from this surgery. Patients generally stay in hospital for one night and can return to work within three to four weeks.

Duodenal Switch

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Short Description Of The Main Bariatric Surgery Procedures Used In Diabetic Patients

Currently accepted bariatric procedures for the treatment of type 2 diabetic patients are Roux-en-Y gastric by-pass , laparoscopic adjusted gastric banding , bilio-pancreatic diversion and duodenal switch variant , and sleeve gastrectomy

The Roux-en-Y gastric bypass is one of the most commonly performed bariatric procedures worldwide. It developed in the late 60s from the observation that patients with partial gastrectomy suffer a significant and persistent weight loss. After successive changes and optimizations, it is now considered the gold-standard in bariatric surgery. The intervention has several components: in the first step, a 30 milliliters stomach pouch is created by dividing the top of the stomach from the rest of it. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is connected to the newly created stomach pouch. In the final step, the top portion of the divided small intestine is connected to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food .

Figure 1.

Roux-en-Y gastric bypass

Figure 2.

Laparoscopic adjusted gastric banding

Figure 3.

Dipeptidyl Peptidase Iv Inhibitors

DPP-4 inhibitors are a class of drugs that prolong the action of incretin hormones. DPP-4 degrades numerous biologically active peptides, including the endogenous incretins GLP-1 and glucose-dependent insulinotropic polypeptide . DPP-4 inhibitors can be used as a monotherapy or in combination with metformin or a TZD. They are given once daily and are weight neutral.

A study comparing the efficacy and safety of monotherapy with sitagliptin or metformin in treatment-naive patients with type 2 diabetes found no statistical differences between the 2 drugs in terms of decreases in HbA1c and fasting glucose levels. The 1050 participants in the study had baseline HbA1c levels of 6.5-9% and received sitagliptin or metformin for 24 weeks.

In this study, the incidence of adverse GI effects was lower with sitagliptin than with metformin . Specifically, diarrhea and nausea were significantly less common with sitagliptin.

A study by Vilsboll et al in patients receiving stable-dose insulin therapy found that the addition of sitagliptin produced a greater reduction in FPG and 2-hour postprandial glucose than did placebo. Sitagliptin reduced HbA1c by 0.6%, while no reduction was seen with placebo. In addition, 13% of patients attained an HbA1c level of less than 7% with sitagliptin, compared with 5% with placebo.

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