|Year : 2014 | Volume
| Issue : 2 | Page : 59-62
Effect of sleeve gastrectomy and gastric bypass on diabetic control in Indore, India
Abhishek Singhai1, Padmnabh Sharma1, Rajesh Kumar Jha2, Pragya Jain2
1 Department of Medicine, Sri Aurobindo Medical College, Indore, Madhya Pradesh, India
2 Department of Ophthalmology, Choithram Netralaya, Indore, Madhya Pradesh, India
|Date of Web Publication||18-Dec-2014|
Department of Medicine, Sri Aurobindo Medical College, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Individual with morbid obesity and type 2 diabetes benefits from weight loss, as this allows better glycemic control and modifies the coexisting risk factors for coronary heart disease, namely hypertension, dyslipidemia, insulin resistance, sleep apnea, and other comorbidities that constitute the metabolic syndrome. Aims: The purposes of the present study were to investigate whether weight loss after bariatric surgery can correct glycemic control and reduces the need of antidiabetic treatment in morbidly obese patient with type 2 diabetes, and whether sleeve gastrectomy or gastric bypass is associated with better control. Settings and Design: This study was performed in Sri Aurobindo Medical College, Indore, India. Sampling taken was nonrandom and purposive. Subjects and Methods: Forty patients with diabetes type-2 and body mass index (BMI) >35 (20 of which undergone sleeve gastrectomy and other 20 undergone gastric bypass) were enrolled in study, all these patient had undergone bariatric surgery. Their obesity status in terms of height, weight and BMI, Glycemic status and glycosylated hemoglobin (HbA1c), and treatment status in terms of oral hypoglycemic agents and insulin were noted in details preoperatively. Qualitative variables were tested using Chi-square test and P values were calculated between two groups. P ≤0.05 was considered statistically significant. Results: This study showed good control of glycemic status with mean HbA1c within desired level after 6 months of bariatric surgery, while gastric bypass surgery was associated with better glycemic control and weight loss. Conclusions: This study showed that the bariatric surgery was an effective option for morbidly obese patients with type 2 diabetes mellitus. Gastric bypass surgery was associated with better diabetic control and weight loss than sleeve gastrectomy.
Keywords: Gastric bypass, obese, sleeve gastrectomy, type 2 diabetes mellitus
|How to cite this article:|
Singhai A, Sharma P, Jha RK, Jain P. Effect of sleeve gastrectomy and gastric bypass on diabetic control in Indore, India. Saudi J Obesity 2014;2:59-62
| Introduction|| |
Epidemiological studies have shown that obesity is a significant risk factor for type 2 diabetes and that 41% of morbidly obese patients have abnormal glycemic control.  Insulin resistance is more pronounced in obese subjects with type 2 diabetes. , It has been shown that progression from normal to impaired glucose tolerance and diabetes is associated with a reduction in insulin sensitivity and a progressive decrease of the acute insulin response to glucose, which is lost at the onset of diabetes. , Moderate weight loss following a low caloric diet can improve insulin action and secretion, but the effect is rather weak.  Metabolic control has been shown to improve the defect of early insulin response only minimally or partially. , Individuals with morbid obesity and type 2 diabetes benefit from weight loss, as this allows better glycemic control and modifies the coexisting risk factors for coronary heart disease, namely hypertension, dyslipidemia, insulin resistance, sleep apnea, and other comorbidities that constitute the metabolic syndrome.  Although weight loss can be achieved by low-calorie diet, exercise, behavior modification, and medical treatment, late weight gain has been an almost universal problem. Conversely bariatric surgeries maintain a weight loss of 33% of body weight for >10 years, the result associated with normalization of glucose levels in most patients with impaired glucose tolerance and type 2 diabetes.  It also normalizes insulin action and secretion in normal glucose tolerant subjects with morbid obesity. ,
The purpose of the present study was to investigate whether weight loss after bariatric surgery can correct glycemic control and reduces the need of antidiabetic treatment in morbidly obese patients with type 2 diabetes.
| Subjects and methods|| |
This study performed in Sri Aurobindo Medical College and PG Institute, Indore, India. Sampling was nonrandom and purposive. Study was performed after consent from subjects and approval from the ethical committee; the data were kept anonymous. Forty type-2 diabetic patients with body mass index (BMI) >35 were enrolled in the study. Twenty patients underwent sleeve gastrectomy after proper preanesthetic evaluation while other 20 patients underwent gastric bypass surgery. Their obesity status in terms of height, weight and BMI, Glycemic status in terms of fasting blood sugar, postprandial blood sugar and glycosylated hemoglobin (HbA1c), and treatment status in terms of oral hypoglycemic agents (OHAs) and insulin were assessed in details preoperatively.
Patients were then discharged and advised to strictly follow dietary advices and to frequently follow up by endocrinologist. The patients were then followed after 3 months, 6 months and 1 year after surgery. The obesity, glycemic and treatment status were assessed in detail on three occasions. Any chronic complications of diabetes mellitus (DM) if developed were also noted.
| Results|| |
[Table 1] shows the baseline and demographic characteristics of study population. Average age, BMI and fasting glucose levels were almost similar in both groups.
|Table 1: Baseline clinical and demographic characteristics of study population|
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Baseline BMI was 44.41 ± 7.2 in laparoscopic sleeve gastrectomy (LSG group), which changed to 29.571 after 1 year of sleeve gastrectomy surgery. P value was significant (<0.001). Baseline BMI was 45.86 ± 5.8 in gastric bypass (LGB group) which changed to 28.91 after 1 year of gastric bypass surgery. P value was again significant (<0.001) [Figure 1].
Baseline average fasting blood glucose (FBG) level was 181.4 mg/dl in LSG group that changed to 121 mg/dl after 1 year of sleeve gastrectomy surgery. While baseline average fasting glucose was 200.8 in LGB group that changed to 121 mg/dl after 1 year of gastric bypass surgery. P value in both groups was significant (<0.001) [Figure 2].
Baseline average HbA1c was 8.54 in LSG group that changed to 6.46 after 1 year of sleeve gastrectomy surgery while baseline average HbA1c was 8.32 in LGB group that changed to 6.26 after 1 year of gastric bypass surgery [Figure 3].
Sixty percent of patients achieved remission from DM after one year of surgery in LSG group while 90% of patients achieved remission from DM after 1 year of surgery in LGB group [Figure 4].
| Discussion|| |
The procedure bariatric surgery was successful in all patients, and weight reduction was impressive, although the patients were still obese six months after the operation with an average BMI ~ 30 kg/m 2 . In this study, it was found that patients showed marked improvement in their diabetic status. About 8% of participants showed complete remission of DM while more than 90% of patients showed a significant decrease in their insulin or OHA demand.
A systematic review and meta-analysis of the English literature reported complete resolution of type 2 diabetes (defined as discontinuation of all diabetes-related medications and blood glucose levels within the normal range) in 78.1% of cases. This percentage increased to 86.6%, when counting patients reporting improvement of glycemic control, and diabetes resolution occurred in concomitance with an average weight loss of 38.5 kg (55.9% of the excess weight). 
Two large studies, by Pories et al.  (330 patients) and Schauer et al.,  focused principally on diabetes outcomes after bariatric surgery. In the former study, mean FBG decreased from clearly diabetic values to near normal levels (117 mg%), and HbA1c fell to normal levels (6.6%) without diabetes medicines in 89% of patients. In the latest study by Schauer et al., researchers provided the in-depth evaluation of the clinical outcome in 240 diabetic morbidly obese bariatric patients with a follow-up rate of 80%. The authors noted that after surgery, weight and BMI decreased from 308 lbs and 50.1 kg/m 2 to 211 lbs and 34 kg/m 2 for a mean weight loss of 97 lbs and mean excess weight loss of 60%. Fasting plasma glucose and HbA1c concentrations returned to normal levels (in 83%) or markedly improved (in 17%) in all patients. A significant reduction in use of oral antidiabetic agents (80%) and insulin (79%) followed surgical treatment was observed.
Two prospective, controlled studies have addressed changes in glycemic control after bariatric surgery. The multicenter Swedish Obese Subjects study compared bariatric surgery with medical weight-loss treatment in well-matched obese patients.  Bariatric surgery caused an average 16.1% weight loss at 10 years compared with a small weight gain in control subjects. Mean FBG tended to increase during the study in nonsurgical controls (+18.7% at 10 years), whereas a substantial decrease was seen in surgical patients at 2 years (−13.6%) and 10 years (−2.5%). The risk of developing diabetes was >3 times lower for surgically treated patients at 10 years, and recovery rates from diabetes were 3 times greater. Dixon et al.  reported a randomized controlled trial comparing bariatric surgery to conventional type 2 diabetes management in subjects with BMI 30-40 kg/m 2 who had early (<2 years duration) and relatively mild diabetes. Bariatric surgery promoted significantly larger reductions in FBG, HbA1c, and diabetes medication usage. Marinari et al.  showed a stunning 97% euglycemia in 268 diabetic patients at 10 years after surgery.
Now, there is enough evidence to state that bariatric surgery may reduce mortality in patients with diabetes. In the analysis by Adams et al.,  deaths attributed to diabetes were reduced by 92%. Thus, there can be little doubt that in very obese patients with type 2 diabetes, bariatric surgery in general is a highly effective means of treating type 2 diabetes.
Limitations of study
Our study has some limitations. First our sample size was small and second we have follow-up data up to 1 year postsurgery. Therefore, a larger trial with long-term follow-up requires to further potentiate our observations.
| Conclusion|| |
This study showed that the bariatric surgery is an effective option for severely obese patients with poor control type 2 DM, and weight loss due to surgery is associated with good glycemic control and improved treatment efficacy. This study also supports that patients undergone gastric bypass surgery are more likely to achieve remission of type 2 DM than sleeve gastrectomy.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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