PMID- 20377665
OWN - NLM
STAT- MEDLINE
DCOM- 20101008
LR  - 20100409
IS  - 1368-504X (Print)
IS  - 1368-504X (Linking)
IP  - 166
DP  - 2010 Feb
TI  - Neuro-modulation and bariatric surgery for type 2 diabetes mellitus.
PG  - 53-8
LID - 10.1111/j.1742-1241.2009.02279.x [doi]
AB  - Obesity has reached epidemic proportions and is continuing to grow into one of 
      the leading healthcare issues worldwide. With this development, bariatric surgery 
      has emerged as an acceptable treatment for morbid obesity, generally achieving 
      meaningful and sustained weight loss. In a surprising turn of events, bariatric 
      surgery was also found to be the most effective therapy for type 2 diabetes 
      mellitus (T2DM). This observation has sparked a great deal of research that has 
      improved our understanding of T2DM pathophysiology; it has facilitated the 
      development of medical treatment and is expanding the indications for bariatric 
      surgery. It was traditionally accepted that bariatric surgery causes weight loss 
      by restriction of gastric volume, intestinal malabsorption, or a combination of 
      the two. Laparoscopic adjustable gastric banding (LAGB) is considered a purely 
      restrictive procedure that involves the placement of an adjustable band around 
      the cardia of the stomach, creating a 15 ml pouch. Laparoscopic sleeve 
      gastrectomy (LSG) is the resection of the fundus all along the greater curvature 
      of the stomach. LSG was once considered a restrictive procedure, but this 
      presumption has recently come under scrutiny. Bilio-pancreatic diversion (BPD) is 
      an example of a procedure that was considered predominantly malabsorptive. In 
      this operation, the ingested nutrients are diverted from the stomach to the 
      ileum, bypassing a large segment of proximal bowel. Roux-en-Y gastric bypass 
      (RYGB) traditionally combines both mechanisms, partitioning a small pouch from 
      the proximal stomach and diverting the ingested nutrients to the jejunum with a 
      roux-en-Y gastro-jejunostomy. However, recent investigation suggests additional 
      mechanisms of action including hormonal. Today, RYGB is the procedure of choice 
      for morbidly obese patients. The effect of bariatric surgery on T2DM was 
      initially described in 1995 by Pories et al., who reported that there was an 
      overall T2DM resolution after RYGB of 82.9% (1). A resolution rate of 
      approximately 80% has been demonstrated repeatedly (2,3). The initial assumption 
      was that the mechanism causing this effect was through weight loss. It is 
      becoming evident that the anti-diabetic effect is not entirely weight loss as 
      there is a consistent observation that the improvement of glucose and insulin 
      levels occurs within days after RYGB, clearly too soon to be due to the weight 
      loss (1,4). The ensuing body of literature has generated two leading theories 
      attempting to explain this weight-independent anti-diabetic effect after RYGB. 
      The 'hindgut' proposes that rapid delivery of partially digested nutrients to the 
      distal bowel up-regulates the secretion of incretins such as glucagon-like 
      peptide-1 (GLP-1). The result of the increased incretin secretion is an enhanced 
      glucose-dependent insulin secretion, as well as a number of other changes causing 
      improved glucose tolerance (4). In the second theory, 'the foregut hypothesis', 
      the exclusion of the duodenum results in the inhibition of a 'putative' signal 
      that is responsible for insulin resistance (IR) and/or abnormal glycaemic 
      control. In a non-obese diabetic rat model, surgical diversion of the proximal 
      bowel caused rapid improvement of diabetes without reduction of food intake or 
      change in weight (5). Many aspects regarding surgical treatment of T2DM are still 
      questionable and unexplained. Emerging data are starting to clarify the 
      mechanisms participating in the anti-diabetic effect, and also challenging 
      long-held theories.
FAU - Spector, D
AU  - Spector D
AD  - Department of Surgery, Tufts Medical Center, Boston, MA, USA. 
      dspector@tuftsmedicalcenter.org
FAU - Shikora, S
AU  - Shikora S
LA  - eng
PT  - Journal Article
PT  - Review
PL  - England
TA  - Int J Clin Pract Suppl
JT  - International journal of clinical practice. Supplement
JID - 9712380
RN  - 0 (Incretins)
RN  - 89750-14-1 (Glucagon-Like Peptide 1)
SB  - IM
MH  - Animals
MH  - *Bariatric Surgery
MH  - Diabetes Mellitus, Type 2/metabolism/*surgery
MH  - Glucagon-Like Peptide 1/metabolism
MH  - Humans
MH  - Incretins/metabolism
MH  - Obesity/metabolism
EDAT- 2010/08/18 06:00
MHDA- 2010/10/12 06:00
CRDT- 2010/04/10 06:00
PHST- 2010/04/10 06:00 [entrez]
PHST- 2010/08/18 06:00 [pubmed]
PHST- 2010/10/12 06:00 [medline]
AID - IJCP2279 [pii]
AID - 10.1111/j.1742-1241.2009.02279.x [doi]
PST - ppublish
SO  - Int J Clin Pract Suppl. 2010 Feb;(166):53-8. doi: 
      10.1111/j.1742-1241.2009.02279.x.