Modified Bariatric Surgery Tames Diabetes in Small Series

HOUSTON – Laparoscopic sleeve gastrectomy with ileal interposition sent diabetes into remission in 20 of 43 adults and reduced the need for diabetes medications in the other 23 patients during an average of 20 months of follow-up.

Among the 30 obese (defined as having a body mass index greater than 27 kg/m²) patients in the study, 26 showed remission of diabetes – an 86% success rate that’s similar to results reported for gastric bypass surgery, Dr. Kirtikumar D. Modi said in a press briefing at the annual meeting of the Endocrine Society.

Patients had an average disease duration of 10 years and an average BMI of 33. In laparoscopic sleeve gastrectomy with ileal interposition, stapling reduces the size of the stomach, and a segment of the ileum is shifted to the jejunal area closer to the stomach. The average BMI fell to 26 after surgery. Among 30 patients who had hypertension before surgery, 27 had no hypertension postoperatively.

The surgery seemed to have no significant effect on lipid levels, "maybe because [the patients] were already on lipid-lowering drugs," said Dr. Modi, chief endocrinologist at Medwin Hospital in Hyderabad, India.

There were few complications; approximately 25% of patients had nausea and loss of appetite during the first postoperative month. Difficulty with rapid swallowing in six patients subsided over 2 weeks.

In a second series, Dr. Modi and his associates performed a laparoscopic diverted sleeve gastrectomy with ileal interposition on 17 additional patients who were not obese and had had diabetes longer than 10 years – the characteristics of patients who responded less well to the sleeve gastrectomy with ileal interposition in the first series.

Laparoscopic diverted sleeve gastrectomy diverts food away from parts of the small intestine, including the duodenum, where the absorption of nutrients begins, and the ileal segment is shifted more proximally. Patients who underwent this procedure had had diabetes for 15 years on average, and they had an average BMI of 29 as well as stimulated C-peptide levels greater than 4 ng/mL.

As expected, the mean BMI decreased to 23 over 18 months, he said. Of the eight patients who had hypertension before surgery, seven (88%) had no hypertension afterward. This time, treatment produced significant decreases in glycemic, lipid, and microalbuminuria levels.

At 9 months after surgery, diabetes was in remission in 12 (70%) of the 17 patients, and the other 5 patients needed fewer oral hyperglycemic medications than did those in the first series.

All patients in both studies had poorly controlled diabetes. The investigators defined diabetes remission as a hemoglobin A_1c level less than 6.5% and no further need for insulin or oral hypoglycemic agents.

The reduction in hemoglobin A_1c was disproportionately greater than the decline in BMI, suggesting benefits that are "much more than the weight improvement," he said.

More complications were seen in the second series, including three patients with minor intraoperative complications. Another patient developed ileus with ileal perforation 2 weeks after surgery and underwent laparotomy for repair. Three patients experienced nausea and anorexia for 2 weeks. Two patients developed vitamin B₁₂ deficiency at 12 months.

A previous study of 150 patients with uncontrolled type 2 diabetes reported better glycemic control in patients who were randomized to 12 months of medical therapy plus bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass), compared with those on medical treatment alone, Dr. Modi noted (N. Engl. J. Med. 2012;366:1567-76).

A separate retrospective study of 271,726 patients in the Bariatric Outcomes Longitudinal Database found that the efficacy and safety of laparoscopic sleeve gastrectomy fell between those of gastric banding and laparoscopic gastric bypass.

Dr. Modi reported having no financial disclosures.

HOUSTON – Laparoscopic sleeve gastrectomy with ileal interposition sent diabetes into remission in 20 of 43 adults and reduced the need for diabetes medications in the other 23 patients during an average of 20 months of follow-up.

Among the 30 obese (defined as having a body mass index greater than 27 kg/m²) patients in the study, 26 showed remission of diabetes – an 86% success rate that’s similar to results reported for gastric bypass surgery, Dr. Kirtikumar D. Modi said in a press briefing at the annual meeting of the Endocrine Society.

Patients had an average disease duration of 10 years and an average BMI of 33. In laparoscopic sleeve gastrectomy with ileal interposition, stapling reduces the size of the stomach, and a segment of the ileum is shifted to the jejunal area closer to the stomach. The average BMI fell to 26 after surgery. Among 30 patients who had hypertension before surgery, 27 had no hypertension postoperatively.

The surgery seemed to have no significant effect on lipid levels, "maybe because [the patients] were already on lipid-lowering drugs," said Dr. Modi, chief endocrinologist at Medwin Hospital in Hyderabad, India.

There were few complications; approximately 25% of patients had nausea and loss of appetite during the first postoperative month. Difficulty with rapid swallowing in six patients subsided over 2 weeks.

In a second series, Dr. Modi and his associates performed a laparoscopic diverted sleeve gastrectomy with ileal interposition on 17 additional patients who were not obese and had had diabetes longer than 10 years – the characteristics of patients who responded less well to the sleeve gastrectomy with ileal interposition in the first series.

Laparoscopic diverted sleeve gastrectomy diverts food away from parts of the small intestine, including the duodenum, where the absorption of nutrients begins, and the ileal segment is shifted more proximally. Patients who underwent this procedure had had diabetes for 15 years on average, and they had an average BMI of 29 as well as stimulated C-peptide levels greater than 4 ng/mL.

As expected, the mean BMI decreased to 23 over 18 months, he said. Of the eight patients who had hypertension before surgery, seven (88%) had no hypertension afterward. This time, treatment produced significant decreases in glycemic, lipid, and microalbuminuria levels.

At 9 months after surgery, diabetes was in remission in 12 (70%) of the 17 patients, and the other 5 patients needed fewer oral hyperglycemic medications than did those in the first series.

All patients in both studies had poorly controlled diabetes. The investigators defined diabetes remission as a hemoglobin A_1c level less than 6.5% and no further need for insulin or oral hypoglycemic agents.

The reduction in hemoglobin A_1c was disproportionately greater than the decline in BMI, suggesting benefits that are "much more than the weight improvement," he said.

More complications were seen in the second series, including three patients with minor intraoperative complications. Another patient developed ileus with ileal perforation 2 weeks after surgery and underwent laparotomy for repair. Three patients experienced nausea and anorexia for 2 weeks. Two patients developed vitamin B₁₂ deficiency at 12 months.

A previous study of 150 patients with uncontrolled type 2 diabetes reported better glycemic control in patients who were randomized to 12 months of medical therapy plus bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass), compared with those on medical treatment alone, Dr. Modi noted (N. Engl. J. Med. 2012;366:1567-76).

A separate retrospective study of 271,726 patients in the Bariatric Outcomes Longitudinal Database found that the efficacy and safety of laparoscopic sleeve gastrectomy fell between those of gastric banding and laparoscopic gastric bypass.

Dr. Modi reported having no financial disclosures.

HOUSTON – Laparoscopic sleeve gastrectomy with ileal interposition sent diabetes into remission in 20 of 43 adults and reduced the need for diabetes medications in the other 23 patients during an average of 20 months of follow-up.

Among the 30 obese (defined as having a body mass index greater than 27 kg/m²) patients in the study, 26 showed remission of diabetes – an 86% success rate that’s similar to results reported for gastric bypass surgery, Dr. Kirtikumar D. Modi said in a press briefing at the annual meeting of the Endocrine Society.

Patients had an average disease duration of 10 years and an average BMI of 33. In laparoscopic sleeve gastrectomy with ileal interposition, stapling reduces the size of the stomach, and a segment of the ileum is shifted to the jejunal area closer to the stomach. The average BMI fell to 26 after surgery. Among 30 patients who had hypertension before surgery, 27 had no hypertension postoperatively.

The surgery seemed to have no significant effect on lipid levels, "maybe because [the patients] were already on lipid-lowering drugs," said Dr. Modi, chief endocrinologist at Medwin Hospital in Hyderabad, India.

There were few complications; approximately 25% of patients had nausea and loss of appetite during the first postoperative month. Difficulty with rapid swallowing in six patients subsided over 2 weeks.

In a second series, Dr. Modi and his associates performed a laparoscopic diverted sleeve gastrectomy with ileal interposition on 17 additional patients who were not obese and had had diabetes longer than 10 years – the characteristics of patients who responded less well to the sleeve gastrectomy with ileal interposition in the first series.

Laparoscopic diverted sleeve gastrectomy diverts food away from parts of the small intestine, including the duodenum, where the absorption of nutrients begins, and the ileal segment is shifted more proximally. Patients who underwent this procedure had had diabetes for 15 years on average, and they had an average BMI of 29 as well as stimulated C-peptide levels greater than 4 ng/mL.

As expected, the mean BMI decreased to 23 over 18 months, he said. Of the eight patients who had hypertension before surgery, seven (88%) had no hypertension afterward. This time, treatment produced significant decreases in glycemic, lipid, and microalbuminuria levels.

At 9 months after surgery, diabetes was in remission in 12 (70%) of the 17 patients, and the other 5 patients needed fewer oral hyperglycemic medications than did those in the first series.

All patients in both studies had poorly controlled diabetes. The investigators defined diabetes remission as a hemoglobin A_1c level less than 6.5% and no further need for insulin or oral hypoglycemic agents.

The reduction in hemoglobin A_1c was disproportionately greater than the decline in BMI, suggesting benefits that are "much more than the weight improvement," he said.

More complications were seen in the second series, including three patients with minor intraoperative complications. Another patient developed ileus with ileal perforation 2 weeks after surgery and underwent laparotomy for repair. Three patients experienced nausea and anorexia for 2 weeks. Two patients developed vitamin B₁₂ deficiency at 12 months.

A previous study of 150 patients with uncontrolled type 2 diabetes reported better glycemic control in patients who were randomized to 12 months of medical therapy plus bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass), compared with those on medical treatment alone, Dr. Modi noted (N. Engl. J. Med. 2012;366:1567-76).

A separate retrospective study of 271,726 patients in the Bariatric Outcomes Longitudinal Database found that the efficacy and safety of laparoscopic sleeve gastrectomy fell between those of gastric banding and laparoscopic gastric bypass.

Dr. Modi reported having no financial disclosures.