La chirurgie bariatrique est aussi à considérer comme le traitement le plus efficace du traitement du diabète de type 2 comme le démontrent les résultas à 10 ans de la Swedish Obese Study SOS. Elle parvient à prévenir le diabète bien mieux que ne le font les mesures hygiéno-diététiques (75% à 10 ans contre 37 à 45% à 4 ans avec les MDH). Mieux, la chirurgie bariatrique multiplie les chances de rémission du diabète d’un facteur 8 à 2 ans et d’un facteur 3,5 à 10 ans et est de surcroît associée à une réduction de la mortalité totale, par cancer et par diabète.
Surgery for nonobese type 2 diabetic patients: an interventional study with duodenal-jejunal exclusion.
Geloneze B, Geloneze SR, Fiori C, Stabe C, Tambascia MA, Chaim EA, Astiarraga BD, Pareja JC.
: Obes Surg. 2009 Aug;19(8):1077-83. Epub 2009 May 12
BACKGROUND: A 24-week interventional prospective trial was performed to compare the benefits of open duodenal-jejunal exclusion surgery (GJB) with a matched control group on standard medical care.
METHODS: One-hundred eighty patients were screened for the surgical approach. Twelve patients accepted to be operated and presented the full eligibility criteria for surgery that includes overweight BMI (25-29.9 kg/m2), T2DM diagnosis for less than 15 years, insulin-treated patients, no history of major complications, preserved beta-cell function, and absence of autoimmunity. A matched control group (CG) of patients whom refused surgical treatment was placed to receive standard care. Patients had age of 50 (5) years, time of diagnosis 9 years (range, 3 to 15 years), time of insulin usage 6 months (range, 3 to 48 months), fasting glucose (FG), 9.8 (2.5) mg/dL, and glycated hemoglobin (A1C) 8.90 (2.12)%.
RESULTS: At 24 weeks after surgery, patients experienced greater reductions on FG (14% vs. 7% on CG), A1C (from 8.78 to 7.84 in GJB-p<0.01 and 8.93 to 8.71 in CG; p<0.05 between groups) and reductions on average daily insulin requirement (93% vs. 29%, p<0.01). Ten patients stopped insulin usage in GJB but they remain taking oral medications. No differences were observed in both groups regarding BMI, body distribution and composition, blood pressure, and lipids.
CONCLUSIONS: In conclusion, duodenal-jejunal exclusion was an effective treatment for nonobese T2DM subjects. GJB was superior to standard care in achieving better glycemic control along with reduction in insulin requirements. |
L’interposition iléale : une nouvelle approche du traitement du diabète indépendamment du poids ?
L’obtention d’une rémission ou d’un parfait contrôle du diabète chez plus de 80% des obèses diabétiques ayant eu un by-pass gastrique pose de nombreuses questions dont celle du mécanisme et celle de l’extension de la chirurgie à l’ensemble des diabétiques non contrôlés, quel que soit leur poids. La transposition iléale consiste à placer une anse iléale terminale entre le duodénum et l’iléon proximale en se basant sur l’hypothèse du « hindgut » qui considère que l’arrivée des nutriments dans cette portion de l’intestin déclenche un signal neuro-hormonal plus précoce et plus puissant stimulant la sécrétion d’insuline selon un effet de type incrétine.
Effect of laparoscopic ileal interposition on beta cell function and insulin sensitivity in non-obese patients with type 2 diabetes mellitus
S. Vencio1, A. DePaula1, A. Macedo2, A. Halpern3, A. Mari4, E. Muscelli5, E. Ferrannini5;
1Hospital de especialidades, Goiania, Brazil, 2Hospital Albert Einstein, São Paulo, Brazil, 3Universidade Estadual de São Paulo, São Paulo, Brazil, 4CNR Institute of biomedical Engineering, Padova, Italy, 5Internal medicine, Università di Pisa, Pisa, Italy.
Background and aims: Bariatric surgery is very effective in achieving weight loss and improving type 2 diabetes mellitus (T2DM) in obese patients. Our aim was to evaluate T2DM in patients with a BMI below 30 kg/m2 the impact of two versions of laparoscopic ileal interposition and sleeve gastrectomy: one in which the duodenum is kept in continuity with the stomach (II-SG) and another in which a diversion of the second portion of the duodenum is applied (II-DSG).:
Subjects and methods: Twenty-two (13M/9F; 58±2 years; BMI=26.0±0.7 kg/m2) and 20 (10M/10F; 60±2 years; BMI=27.3±0.3 kg/m2) T2DM patients underwent II-SG and II-DSG, respectively. A standard OGTT (75 g) was performed before and 8-15 months after surgery; C-peptide deconvolution and mathematical modelling were used to reconstruct insulin secretion rates and beta cell function. In particular, beta cell glucose sensitivity (b-GS, slope of the insulin secretion/glucose concentration dose-response curve) and total insulin output in response to oral glucose (TIR) were calculated. Insulin sensitivity was estimated from the plasma glucose and insulin responses by the OGIS (Oral Glucose Insulin Sensitivity) index.
Results: Mean A1c decreased from 8.15 +- 2.1% to 6.06 +- 1.19 %. With II-SG, BMI fell to 21.3±0.3 kg/m2 (p<0.05). Fasting plasma glucose (9.4±0.7 vs 6.6±0.3 mmol/l, p<<.001), 2-hour glucose (20.0±1.1 vs 9.3±1.0 mmol/l, p<0.001) and incremental glucose area-under-curve (AUGC) (902±59 vs 643±76 mmol.1-1.h-1, p<0.05) were lower after surgery. Similar effects were seen after II-DSG (BMI to 22.3±0.6, p<0.0001, fasting plasma glucose, 11.3±1.1 vs 6.3±0.5mmol/l, p<0.001; 2-hour glucose, 19.8±1.2 vs 10.1±1.1 mmol/l, p<0.001). TIR increased from 36.8±4.3 to 55.0±6.5 nmol/m2 (p<0.05) with II-SG and from 41.3±3.4 to 53.6±3.4nmol/m2 (p<0.05) with II-DSG, while b-GS rose from 18±4 to 47±7 pmol.min-1.m-2.mM-1 (p<0.001) with II-SG and from 24±5 to 42±6 pmol.min-1.m-2.mM-1 with II-DSG (p<0.05). Insulin sensitivity rose from 265±37 to 410±20 ml.min-1.m-2 (p<0.001) with II-SG and from 218±23 to 428±19 ml.min-1.m-2 (p<0.001) with II-DSG. In the pooled data from both groups, the changes in 2-hour-glucose concentration were independently related to the changes in BMI (standardised r=-0.20), b-GS (standardised r=-0.36) and OGIS (standardised r=-0.59), with a total explained variance of 72%, p<0.0001.
Conclusion: In non-obese (BMI<30) T2DM, laparoscopic ileal interposition/sleeve gastrectomy, with or without diversion, effectively improves glucose tolerance by augmenting both beta cell function and insulin sensitivity. These findings lend support to the concept that the terminal ileum releases neuroendocrine signals in response to feeding which favourably impact on glucose tolerance (hindgut hypothesis). |
