Last updated date: 16-Jan-2022
Originally Written in English
Bariatric Surgery. An effective treatment option for obesity and diabetes
What is bariatric surgery?
According to the American Society for metabolic and Bariatric Surgery (ASBMS), bariatric surgical procedures cause weight loss by restricting the amount of food the stomach can hold, causing malabsorption of nutrients, or by a combination of both gastric restriction and malabsorption. Bariatric procedures also often cause hormonal changes. Most weight loss surgeries today are performed using minimally invasive techniques (laparoscopic surgery).
The most common bariatric surgery procedures are gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch. Each surgery has its own advantages and disadvantages.
Can bariatric surgery be a treatment option for obesity and diabetes? Many studies and practice point to a “yes” as the answer. According to Diabetes Spectrum, obesity and diabetes are two often interrelated and escalating health problems. For patients with clinically severe obesity and diabetes, surgery provides the best option for the cure of both disease processes. However, the resolution of diabetes may not result from weight loss alone, but instead may be caused by (surgical) alteration of the enteroinsular axis, as well.
The prevalence of diabetes is estimated at more than 135 million worldwide. These numbers are expected to increase in the coming decades, translating to an economic burden of > $100 billion in direct and indirect health care costs in the United States alone. The worldwide prevalence of diabetes is expected to increase to 300 million by the year 2025.
There are four most common types of bariatric surgery (source: ASMBS.org):
This procedure is the most popular form of bariatric surgery when attempting to cause weight loss. There are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine 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.
The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less calories consumed. Additionally, because there is less digestion of food by the smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, there is probably to some degree less absorption of calories and nutrients.
Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety (feeling of fullness), suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.
The Laparoscopic Sleeve Gastrectomy, often called the sleeve, is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana. First, the new stomach pouch holds a considerably smaller volume than the normal stomach and helps to significantly reduce the amount of food (and thus calories) that can be consumed. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger, satiety, and blood sugar control as a result of significantly lowered food intake. Short term studies show that the sleeve is as effective as the gastric bypass in terms of weight loss and improvement or control of remission of diabetes. There is also evidence that suggest the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of the weight loss.
Adjustable Gastric Band
The Adjustable Gastric Band, often simply called the “band”, involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band, and the rest of the stomach below the band. The common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote satiety. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin. Reducing the size of the opening is done slowly over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged by studies that show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band. What is known is that there is no malabsorption; the food is digested and absorbed normally.
The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the number of calories that are consumed.
Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Gastric Bypass
The Biliopancreatic Diversion with Duodenal Switch (BPD/DS) is a two-step procedure. First, a smaller, tubular stomach pouch is created by removing a portion of the stomach, then, a large portion of the small intestine is bypassed. The duodenum is divided just past the outlet of the stomach. A segment of the distal small intestine is then brought up and connected to the outlet of the newly created stomach, so that when the patient eats, the food goes through a newly created tubular stomach pouch and empties directly into the last segment of the small intestine. Roughly three-fourths of the small intestine is bypassed by the food stream. The bypassed small intestine, which carries the bile and pancreatic enzymes that are necessary for the breakdown and absorption of protein and fat, is reconnected to the last portion of the small intestine so that they can eventually mix with the food stream. Similar to the other surgeries described above, the BPD/DS first helps to reduce the amount of food that is consumed; however, over time this effect lessens and patients are able to eventually consume near “normal” amounts of food. Unlike the other procedures, there is a significant amount of small bowel that is bypassed by the food stream.
Additionally, the food does not mix with the bile and pancreatic enzymes until very far down the small intestine. This results in a significant decrease in the absorption of calories and nutrients (particularly protein and fat) as well as nutrients and fat-soluble vitamins. Lastly, the BPD/DS, similar to the gastric bypass and sleeve gastrectomy, affects guts hormones in a manner that impacts hunger and satiety as well as blood sugar control. The BPD/DS is considered to be the most effective surgery for the treatment of diabetes among the procedures described here.
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