- Email: [email protected]
Does preoperative diabetes mellitus affect weight loss outcome after biliopancreatic diversion with duodenal switch?
Surgery for Obesity and Related Diseases ] (2015) 00–00
Original article
Does preoperative diabetes mellitus affect weight loss outcome after biliopancreatic diversion with duodenal switch? Moaz Abulfaraj, M.D., F.R.C.S.C.*, Amarita Klar, M.D., Iswanto Sucandy, M.D., Gintaras Antanavicius, M.D., F.A.C.S. Department of Surgery, Abington Memorial Hospital, Abington, Pennsylvania
Abstract
Background: Preoperative type 2 diabetes mellitus (T2 DM) has previously been reported as an independent predictor for suboptimal (r40%) weight loss after Roux-en-Y gastric bypass in patients with T2 DM compared with patients who do not have T2 DM. This association has not been shown to apply to patients who undergo biliopancreatic diversion with duodenal switch (BPD/DS). BPD/DS is currently the most effective bariatric operation to treat T2 DM. Objectives: We designed a study to determine if the reported suboptimal weight loss seen in patients with T2 DM undergoing Roux-en-Y gastric bypass is also seen in those undergoing BDP/DS. Setting: Independent, university-affiliated teaching hospital. Materials and Methods: Retrospective chart review of a prospectively maintained database was performed on data on 152 patients who underwent robotically assisted laparoscopic BPD/DS from 2008 to 2012. Patients were divided into 2 groups: those with a preoperative diagnosis of T2 DM (Group 1, n ¼ 51) versus those without a preoperative diagnosis of T2 DM (Group 2, n ¼ 101). Perioperative complications and postoperative weight loss between the 2 groups were compared. Results: At 1 month postoperatively, Group 1 had a higher percentage of excess weight loss (%EWL) of 20.9% compared with Group 2 of 17.9% (P o .05). At 3, 6, 9, 12, and 18 months postoperatively, both groups had statistically comparable %EWL (P 4 .05). Thirty-day perioperative complications were higher in Group 1 compared with those in Group 2 (7.8% and 3.9%, respectively). Reoperation rates were similar in both groups (1.9%). No mortality was recorded in this series. Conclusion: Patients with diabetes had a similar weight loss outcome after BPD/DS compared with those who did not have diabetes. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Biliopancreatic diversion; Duodenal switch; Diabetes mellitus; Weight loss outcomes
Bariatric surgery has been proven to be significantly more effective than purely conventional medical therapy at initial weight loss and long-term weight maintenance. Multiple procedures have been performed to achieve these goals, which include Roux-en-Y gastric bypass (RYGB) * Correspondence: Moaz Abulfaraj, M.D., F.R.C.S.C., Department of Surgery, Abington Memorial Hospital, 1200 Old York Road, Abington, Pennsylvania 19001, USA. E-mail: [email protected]
and biliopancreatic diversion (BPD) with and without duodenal switch (BPD/DS). BPD was first described by Scopinaro in 1979: He performed a distal gastrectomy with a 250-mL pouch and a distal small bowel bypass with a 200-cm alimentary limb and 50-cm common channel [1]. In 1993, Marceau, from Québec, Canada, modified the operation by performing a vertical sleeve gastrectomy (VSG) and duodenal switch and increasing the length of the common channel to 100 cm [2]. BPD/DS is currently the
http://dx.doi.org/10.1016/j.soard.2015.06.006 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
M. Abulfaraj et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
most effective and durable bariatric operation for weight loss [3,4]. In recent years, numerous factors have been postulated to be associated with suboptimal weight loss after bariatric surgery. In multiple RYGB studies, preoperative diabetes mellitus (DM) has been shown to negatively affect weight loss outcome [5–9]. Several possible explanations have been provided in the literature. It is unclear if a similar phenomenon is also seen in patients who undergo BPD/DS. We designed a study to evaluate if suboptimal weight loss was seen in patients with type 2 DM (T2 DM) undergoing BPD-DS.
had a diagnosis of T2 DM preoperatively (n ¼ 51), and Group 2 did not (n ¼ 101). Approximately 50% of patients in the DM group required subcutaneous insulin injection (at least 10 units of regular insulin daily) in addition to oral antidiabetic medication (metformin 500–1000 mg once or twice daily) for management of T2 DM. The average length of time between the T2 DM diagnosis and the BPD/DS was 5 years. Perioperative complications and postoperative weight loss between the 2 groups were compared. All patients were seen in our bariatric office for postoperative follow-up at 1 week, 1 month, 3 months, 6 months, and 1 year thereafter.
Materials and methods
Operative technique
A prospectively maintained database of all patients who underwent consecutive robotically assisted or laparoscopic BPD/DS (n = 152) at our institution between 2008 and 2012 was reviewed. Our bariatric surgeon (senior author) performed 234 operations during the study period, with approximately 65% of them being BPD/DS procedures. The remainder of the patients underwent laparoscopic RYGB and VSG; we did not routinely offer laparoscopic adjustable gastric banding in our bariatric center during the study period. All the 152 study patients who underwent BPD/DS were operated on by a single, fellowship-trained bariatric surgeon. All patients met the National Institute of Health (NIH) consensus guidelines (body mass index [BMI] over 40 kg/m2 or 35–40 kg/m2 with obesity related co-morbidities) [10]. DM was defined as blood glucose (HgA1c) levels 47. Patients who were on antidiabetic medications, such as oral agents or as subcutaneous insulin injections, were classified in the DM group. In our bariatric center, selection criteria for BPD/DS include BMI Z50 kg/m2 (super-obese category); severe DM defined as HgA1c 410 despite maximum medical therapy using insulin and oral antidiabetic agents; absence of prior major abdominal operations that may potentially cause technical limitations in performing or completing BPD/DS; and, ultimately, the patient’s preference. Patients who met these criteria were given a strong recommendation to undergo BPD/DS, whereas those who did not meet the criteria were given alternative options of undergoing RYGB or VSG. Patients with severe diabetes (HgA1c above 10) were recommended to undergo BPD/DS despite their lower BMI (35–50 kg/m2). All patients underwent preoperative counseling with the bariatric surgeon and extensive education with a bariatric dietician. They were also evaluated and cleared by a psychiatrist and other medical services, when indicated. A quiz was conducted to ensure that all patients fully understood the operation and the commitments required postoperatively. Appropriate informed consent was obtained from all patients. In this study, patients were divided preoperatively into 2 groups based on presence or absence of T2 DM. Group 1
All BPD/DS procedures were performed laparoscopically with the assistance of a DaVinci robotic system. A single dose of prophylactic antibiotic, subcutaneous heparin, and sequential compressive stockings/device were administered preoperatively. After gaining access into the peritoneal cavity, the left lobe of the liver was retracted superiorly using a 5-mm Flex (Cardinal Health, Dublin, OH) retractor. The greater omentum was dissected off the greater curvature of the stomach all the way to the left crus of the diaphragm. A VSG was performed over a 42-French bougie using multiple firings of Echelon Flex power endopath linear staplers (Ethicon, Albuquerque, NM). The gastric staple line was imbricated with a running suture by using an Endostitch (Covidien, Dublin, Ireland). The junction between the first and second portions of the duodenum was mobilized, and a retroduodenal window was created. The Echelon stapler was used to transect the duodenum. An appendectomy was routinely performed as a part of standard BPD/DS operation, to avoid potential future appendicitis. Starting from the ileocecal valve, 100 cm of ileum was measured in a retrograde manner and marked to be the common channel. Another 150 cm of small intestine was measured to be the alimentary limb and divided. The ileum was then approximated to the proximal duodenal stump to create an end-to-side duodenoileal anastomosis. A posterior layer suture of the duodenoileal anastomosis was placed laparoscopically, and the robotic system was used to complete a 2-layer hand-sewn duodenoileal anastomosis. A nasogastric tube was used to guide the creation of the anastomosis. A leak test using methylene blue was performed. The resected stomach was removed through a supraumbilical port. The fascia was closed, and the ports were removed. Most patients were discharged by postoperative day 3 after tolerating a noncaloric liquid diet. Results In this study, 152 obese patients who underwent laparoscopic/robotic assisted BPD/DS between 2008 and 2012
Preoperative Diabetes Mellitus and Weight Loss Outcome / Surgery for Obesity and Related Diseases ] (2015) 00–00 Table 1 Patients demographic and perioperative outcomes
Age (y) Body mass index (kg/m2) Mean operative time (min) Mean length of stay (days) Reoperation rate, n (%) 30-day complication, n (%) Mortality (%)
Group I; n ¼ 51 (DM)
Group II; n ¼ 101 (non-DM)
47.8 (range: 23–72) 47.2 (range: 35–70) 269 2.9 1 (1.9) 4 (7.8) 0
42.4 (range: 20–69) 51.3 (range: 37–69) 263 2.6 2 (1.9) 4 (3.9) 0
DM ¼ Diabetes mellitus.
were included (Table 1). The patients were divided into 2 groups. The first group included all patients who had DM before the surgery, and the second group included all patients who did not have DM. The first group had 51 patients, and the second group had 101 patients. The majority of the patients were female (71%); gender distribution was identical in both groups. The average age was 47.8 years in the DM group and 42.4 years in the non-DM group. The average BMI was lower in the DM group compared with that of the non-DM group (47.2 versus 51.3 kg/m2, respectively). The average operative time was comparable in both groups (269 min for the DM group and 263 min for the non-DM group). No anastomotic/staple line leak, bleeding, deep venous thrombosis, or pulmonary embolism was seen in either group. All cases were completed minimally invasively, without the use of additional ports or conversion to the open approach. The average length of hospital stay was slightly longer in the DM group, but not statistically significant (2.9 versus 2.6 days, respectively). In the DM group, 1 patient stayed for 13 days because of severe portsite infection, which required return to the operating room for incision and drainage. Another patient stayed for 9 days because of exacerbation of carpal tunnel syndrome. One patient in the DM group developed early pyelonephritis, and another patient with type 1 DM developed diabetic ketoacidosis. Two patients in the non-DM group underwent reoperation within 30 days postoperatively. One patient developed an incarcerated port-site hernia, which required laparoscopic exploration and hernia repair during the same hospital admission. Another patient had an inadvertently sutured nasogastric tube during the creation of the duodenojejunostomy, which required endoscopic release in the operating room on postoperative day 1 [11]. Other 30-day postoperative complications in the non-DM group included hospital-acquired pneumonia and urosepsis related to obstructing kidney stones. All in the DM group, except 2 patients (96%), no longer required insulin to control their blood glucose immediately following the operation. Fingerstick blood glucose measurements were performed by the nursing staff every 6 hours during the postoperative phase until discharge from the
3
hospital. One patient with type 1 DM required subcutaneous insulin injection for glucose control, postoperatively. She made an uneventful recovery and was finally discharged home on one-third of the preoperative insulin dose. Another patient in the DM group temporarily required low-dose insulin on postoperative day 1. On postoperative day 2, her blood sugar stabilized, and she no longer required insulin. All oral antidiabetic agents were permanently discontinued after BPD/DS. The average excess weight loss was higher in the DM group at 1 month. The average percentage of excess weight loss (%EWL) for the DM and non-DM groups at 1 month was 20.9 and 17.9, respectively. The %EWL was comparable at 3, 6, 9, 12, and 18 months (Table 2, Fig. 1). The rate of follow-up was a 100% at 1, 3, and 6 months, 92% at 9 and 12 months, and 85.4% at 18 months.
Discussion It has been well established that bariatric surgery is more effective in achieving initial as well as long-term weight loss compared with conventional medical therapy alone. The mechanism of resolution of T2 DM following bariatric surgery for malabsorption has not been completely understood; it is unlikely to be only attributed to the decreased caloric intake because improved glucose control can be as early as few hours postoperatively. Guidone et al. studied the pathophysiologic mechanisms of rapid resolution of T2 DM in 10 obese patients who underwent BDP/DS [12]. Their study showed decrease in plasma concentration of glucose-dependent insulinotropic polypeptide, which is secreted by the duodenum, and elevation in plasma level of glucagon-like peptide-1, which is secreted by the distal small bowel. These changes ultimately cause improvement of beta-cell sensitivity to glucose and reduction of peripheral insulin resistance. BPD/DS is currently the most effective bariatric operation for weight loss as well as resolution of obesity-related metabolic co-morbidities, such as DM, hypertension, and hyperlipidemia [3]. Cho et al. reported that overall 91% of BPD/DS patients achieved resolution of DM postoperatively, with complete resolution of DM in all patients who had been on oral antidiabetics or on insulin for o 5 years Table 2 Excess weight loss outcome after BPD/DS Group
1 month
3 months
6 months
9 months
12 months
18 months
I (DM) % II (non-DM) % P value
20.9 17.9
37.1 35.6
53.9 53.1
64.8 66.4
73.6 75.7
80.1 81.2
.0
.4
.8
.6
.6
.8
BPD/DS ¼ Biliopancreatic diversion with duodenal switch; DM ¼ diabetes mellitus.
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M. Abulfaraj et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
BPD/DS = Biliopancreatic Diversion with Duodenal Switch DM = Diabetes Mellitus
Fig. 1. Comparison of weight loss outcome after biliopancreatic diversion with duodenal switch (BPD/DS).
[4]. The resolution of DM in those who undergo BPD/DS is significantly higher than in those who undergo gastric bypass (84%) or adjustable gastric banding (48%) [13]. A previously described drawback of RYGB is the suboptimal weight loss in certain groups of patients [5–9]. Factors that have been reported to contribute to this phenomenon include black race, male gender, marriage, older age, greater initial weight, open approach, larger pouch, and DM status [5,8,14,15]. However, after multivariate analysis, the only 2 remaining factors that were independently associated with poor weight loss were large gastric pouch size and DM status. Patients with DM controlled using insulin rather than oral antihyperglycemics were at a particularly greater disadvantage, experiencing even less postoperative weight loss. Campos et al. reported that 12.3% of patients with DM had poor %EWL, whereas only 8.2% of patients without DM had poor %EWL. Among the patients with DM who had poor %EWL, 18.4% were on oral antihyperglycemic agents and 22.2% were on insulin regiments [8]. It is possible that the suboptimal postoperative weight loss after RYGB in patients with DM is related to a higher degree of insulin resistance; therefore, they require higher circulating levels of insulin to achieve glucose homeostasis. As insulin itself is an anabolic hormone, it may be one of many factors contributing to suboptimal postoperative weight loss [16]. The United Kingdom Prospective Diabetes Study (UKPDS) described that, although treatment of DM using insulin may cause fewer microvascular complications,
it may inadvertently promote weight gain related to its anabolic effect [17]. In our study, the discrepancy in preoperative BMI between the DM and non-DM groups was likely because the patients with DM were more likely to be advised to have operations for malabsorption (i.e., BPD/DS or RYGB) despite having lower BMI (35–50 kg/m2). In our study, morbidly obese patients with severely elevated HgA1c (410) were advised to undergo BPD/DS despite their BMI being o50 kg/m2. In our bariatric program, with a close and aggressive follow-up protocol, we have not seen long-term severe malnutrition problems as typically described after BPD/DS. Of the 152 patients who underwent BPD/DS at our institution, at 1 month postoperatively, the DM group had a higher %EWL (20.9%) compared with the non-DM group (17.9%). At 3, 6, 9, 12, and 18 months postoperatively, both groups had comparable %EWL. Therefore, unlike the suboptimal weight loss seen in patients with DM who underwent RYGB in other studies, those who underwent BPD/DS achieved excellent postoperative weight loss, comparable with that in patients without DM. The suboptimal weight loss in gastric bypass patients with DM should theoretically still apply to those who underwent BPD/DS; however; the weight loss outcome is clearly not similar. Therefore, morbidly obese patients with T2 DM have a potentially greater benefit from BPD/ DS compared with RYGB. Additionally, they were shown to have equivalent postoperative weight loss compared with those without T2 DM.
Preoperative Diabetes Mellitus and Weight Loss Outcome / Surgery for Obesity and Related Diseases ] (2015) 00–00
Conclusion Even though DM status has previously been reported as an independent predictor for suboptimal weight loss after RYGB, it does not predict weight loss outcome after BPD/ DS. Patients with DM who undergo BPD/DS achieve a higher %EWL at 1 month postoperatively compared with those without DM. At 3, 6, 9, 12, and 18 months after BPD/ DS, patients with or without DM achieve similar %EWL. References [1] Scopinaro N, Gianetta E, Civalleri D. Bilio-pancreatic bypass for obesity: II. Initial experience in man. Br J Surg 1979;66(9):618–20. [2] Marceau P, Biron S, Bourque RA. Biliopancreatic diversion with a new type of gastrectomy. Obes Surg 1993;3(1):29–35. [3] Dorman RB, Rasmus NF, al-Haddad BJ. Benefits and complications of the duodenal switch/biliopancreatic diversion compared to the Roux-enY gastric bypass. Surgery 2012;152(4):758–65, discussion 765–67. [4] Cho EY, Kemmet O, Frenken M, et al. Biliopancreatic diversion with duodenal switch in patients with type 2 diabetes mellitus: is the chance of complete remission dependent on therapy and duration of insulin treatment? Obes Facts 2011;4(Suppl 1):18–23. [5] Ma Y, Pagoto SL, Olendzki BC, et al. Predictors of weight status following laparoscopic gastric bypass. Obes Surg 2006;16(9):1227–31. [6] Carbonell AM, Wolfe LG, Meador JG. Does diabetes affect weight loss after gastric bypass? Surg Obes Relat Dis 2008;4(3):441–4. [7] Júnior WS, do Amaral JL, Nonino-Borges CB. Factors related to weight loss up to 4 years after bariatric surgery. Obes Surg 2011;21 (11):1724–30.
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[8] Campos GM, Rabl C, Mulligan K, et al. Factors associated with weight loss after gastric bypass. Arch Surg 2008;143(9):877–84. [9] Melton GB, Steele KE, Schweitzer MA. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes. J Gastrointest Surg 2008;12 (2):250–5. [10] National Institutes of Health. Gastrointestinal surgery for severe obesity: Consensus Development Conference Panel. Ann Intern Med 1991;115(12):956–61. [11] Sucandy I, Antanavicius G. A novel use of endoscopic cutter: endoscopic retrieval of a retained nasogastric tube following a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch. N Am J Med Sci 2011;3(10):486–8. [12] Guidone C, Manco M, Valera-Mora E. Mechanisms of recovery from type 2 diabetes after malabsorptive bariatric surgery. Diabetes 2006;55(7):2025–31. [13] Buchwald H, Estok R, Fahrbach K. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009;122(3):248–56. [14] Lutfi R, Torquati A, Sekhar N. Predictors of success after laparoscopic gastric bypass: a multivariate analysis of socioeconomic factors. Surg Endosc. 2006;20(6):864–7. [15] Melton GB, Steele KE, Schweitzer MA, et al. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes. J Gastrointest Surg 2008;12 (2):250–5. [16] Flier J, Maratos-Flier E. Energy homeostasis and body weight. Curr Biol 2000;10(6):R215–7. [17] Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352(9131):837–53.
Original article
Does preoperative diabetes mellitus affect weight loss outcome after biliopancreatic diversion with duodenal switch? Moaz Abulfaraj, M.D., F.R.C.S.C.*, Amarita Klar, M.D., Iswanto Sucandy, M.D., Gintaras Antanavicius, M.D., F.A.C.S. Department of Surgery, Abington Memorial Hospital, Abington, Pennsylvania
Abstract
Background: Preoperative type 2 diabetes mellitus (T2 DM) has previously been reported as an independent predictor for suboptimal (r40%) weight loss after Roux-en-Y gastric bypass in patients with T2 DM compared with patients who do not have T2 DM. This association has not been shown to apply to patients who undergo biliopancreatic diversion with duodenal switch (BPD/DS). BPD/DS is currently the most effective bariatric operation to treat T2 DM. Objectives: We designed a study to determine if the reported suboptimal weight loss seen in patients with T2 DM undergoing Roux-en-Y gastric bypass is also seen in those undergoing BDP/DS. Setting: Independent, university-affiliated teaching hospital. Materials and Methods: Retrospective chart review of a prospectively maintained database was performed on data on 152 patients who underwent robotically assisted laparoscopic BPD/DS from 2008 to 2012. Patients were divided into 2 groups: those with a preoperative diagnosis of T2 DM (Group 1, n ¼ 51) versus those without a preoperative diagnosis of T2 DM (Group 2, n ¼ 101). Perioperative complications and postoperative weight loss between the 2 groups were compared. Results: At 1 month postoperatively, Group 1 had a higher percentage of excess weight loss (%EWL) of 20.9% compared with Group 2 of 17.9% (P o .05). At 3, 6, 9, 12, and 18 months postoperatively, both groups had statistically comparable %EWL (P 4 .05). Thirty-day perioperative complications were higher in Group 1 compared with those in Group 2 (7.8% and 3.9%, respectively). Reoperation rates were similar in both groups (1.9%). No mortality was recorded in this series. Conclusion: Patients with diabetes had a similar weight loss outcome after BPD/DS compared with those who did not have diabetes. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Biliopancreatic diversion; Duodenal switch; Diabetes mellitus; Weight loss outcomes
Bariatric surgery has been proven to be significantly more effective than purely conventional medical therapy at initial weight loss and long-term weight maintenance. Multiple procedures have been performed to achieve these goals, which include Roux-en-Y gastric bypass (RYGB) * Correspondence: Moaz Abulfaraj, M.D., F.R.C.S.C., Department of Surgery, Abington Memorial Hospital, 1200 Old York Road, Abington, Pennsylvania 19001, USA. E-mail: [email protected]
and biliopancreatic diversion (BPD) with and without duodenal switch (BPD/DS). BPD was first described by Scopinaro in 1979: He performed a distal gastrectomy with a 250-mL pouch and a distal small bowel bypass with a 200-cm alimentary limb and 50-cm common channel [1]. In 1993, Marceau, from Québec, Canada, modified the operation by performing a vertical sleeve gastrectomy (VSG) and duodenal switch and increasing the length of the common channel to 100 cm [2]. BPD/DS is currently the
http://dx.doi.org/10.1016/j.soard.2015.06.006 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
M. Abulfaraj et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
most effective and durable bariatric operation for weight loss [3,4]. In recent years, numerous factors have been postulated to be associated with suboptimal weight loss after bariatric surgery. In multiple RYGB studies, preoperative diabetes mellitus (DM) has been shown to negatively affect weight loss outcome [5–9]. Several possible explanations have been provided in the literature. It is unclear if a similar phenomenon is also seen in patients who undergo BPD/DS. We designed a study to evaluate if suboptimal weight loss was seen in patients with type 2 DM (T2 DM) undergoing BPD-DS.
had a diagnosis of T2 DM preoperatively (n ¼ 51), and Group 2 did not (n ¼ 101). Approximately 50% of patients in the DM group required subcutaneous insulin injection (at least 10 units of regular insulin daily) in addition to oral antidiabetic medication (metformin 500–1000 mg once or twice daily) for management of T2 DM. The average length of time between the T2 DM diagnosis and the BPD/DS was 5 years. Perioperative complications and postoperative weight loss between the 2 groups were compared. All patients were seen in our bariatric office for postoperative follow-up at 1 week, 1 month, 3 months, 6 months, and 1 year thereafter.
Materials and methods
Operative technique
A prospectively maintained database of all patients who underwent consecutive robotically assisted or laparoscopic BPD/DS (n = 152) at our institution between 2008 and 2012 was reviewed. Our bariatric surgeon (senior author) performed 234 operations during the study period, with approximately 65% of them being BPD/DS procedures. The remainder of the patients underwent laparoscopic RYGB and VSG; we did not routinely offer laparoscopic adjustable gastric banding in our bariatric center during the study period. All the 152 study patients who underwent BPD/DS were operated on by a single, fellowship-trained bariatric surgeon. All patients met the National Institute of Health (NIH) consensus guidelines (body mass index [BMI] over 40 kg/m2 or 35–40 kg/m2 with obesity related co-morbidities) [10]. DM was defined as blood glucose (HgA1c) levels 47. Patients who were on antidiabetic medications, such as oral agents or as subcutaneous insulin injections, were classified in the DM group. In our bariatric center, selection criteria for BPD/DS include BMI Z50 kg/m2 (super-obese category); severe DM defined as HgA1c 410 despite maximum medical therapy using insulin and oral antidiabetic agents; absence of prior major abdominal operations that may potentially cause technical limitations in performing or completing BPD/DS; and, ultimately, the patient’s preference. Patients who met these criteria were given a strong recommendation to undergo BPD/DS, whereas those who did not meet the criteria were given alternative options of undergoing RYGB or VSG. Patients with severe diabetes (HgA1c above 10) were recommended to undergo BPD/DS despite their lower BMI (35–50 kg/m2). All patients underwent preoperative counseling with the bariatric surgeon and extensive education with a bariatric dietician. They were also evaluated and cleared by a psychiatrist and other medical services, when indicated. A quiz was conducted to ensure that all patients fully understood the operation and the commitments required postoperatively. Appropriate informed consent was obtained from all patients. In this study, patients were divided preoperatively into 2 groups based on presence or absence of T2 DM. Group 1
All BPD/DS procedures were performed laparoscopically with the assistance of a DaVinci robotic system. A single dose of prophylactic antibiotic, subcutaneous heparin, and sequential compressive stockings/device were administered preoperatively. After gaining access into the peritoneal cavity, the left lobe of the liver was retracted superiorly using a 5-mm Flex (Cardinal Health, Dublin, OH) retractor. The greater omentum was dissected off the greater curvature of the stomach all the way to the left crus of the diaphragm. A VSG was performed over a 42-French bougie using multiple firings of Echelon Flex power endopath linear staplers (Ethicon, Albuquerque, NM). The gastric staple line was imbricated with a running suture by using an Endostitch (Covidien, Dublin, Ireland). The junction between the first and second portions of the duodenum was mobilized, and a retroduodenal window was created. The Echelon stapler was used to transect the duodenum. An appendectomy was routinely performed as a part of standard BPD/DS operation, to avoid potential future appendicitis. Starting from the ileocecal valve, 100 cm of ileum was measured in a retrograde manner and marked to be the common channel. Another 150 cm of small intestine was measured to be the alimentary limb and divided. The ileum was then approximated to the proximal duodenal stump to create an end-to-side duodenoileal anastomosis. A posterior layer suture of the duodenoileal anastomosis was placed laparoscopically, and the robotic system was used to complete a 2-layer hand-sewn duodenoileal anastomosis. A nasogastric tube was used to guide the creation of the anastomosis. A leak test using methylene blue was performed. The resected stomach was removed through a supraumbilical port. The fascia was closed, and the ports were removed. Most patients were discharged by postoperative day 3 after tolerating a noncaloric liquid diet. Results In this study, 152 obese patients who underwent laparoscopic/robotic assisted BPD/DS between 2008 and 2012
Preoperative Diabetes Mellitus and Weight Loss Outcome / Surgery for Obesity and Related Diseases ] (2015) 00–00 Table 1 Patients demographic and perioperative outcomes
Age (y) Body mass index (kg/m2) Mean operative time (min) Mean length of stay (days) Reoperation rate, n (%) 30-day complication, n (%) Mortality (%)
Group I; n ¼ 51 (DM)
Group II; n ¼ 101 (non-DM)
47.8 (range: 23–72) 47.2 (range: 35–70) 269 2.9 1 (1.9) 4 (7.8) 0
42.4 (range: 20–69) 51.3 (range: 37–69) 263 2.6 2 (1.9) 4 (3.9) 0
DM ¼ Diabetes mellitus.
were included (Table 1). The patients were divided into 2 groups. The first group included all patients who had DM before the surgery, and the second group included all patients who did not have DM. The first group had 51 patients, and the second group had 101 patients. The majority of the patients were female (71%); gender distribution was identical in both groups. The average age was 47.8 years in the DM group and 42.4 years in the non-DM group. The average BMI was lower in the DM group compared with that of the non-DM group (47.2 versus 51.3 kg/m2, respectively). The average operative time was comparable in both groups (269 min for the DM group and 263 min for the non-DM group). No anastomotic/staple line leak, bleeding, deep venous thrombosis, or pulmonary embolism was seen in either group. All cases were completed minimally invasively, without the use of additional ports or conversion to the open approach. The average length of hospital stay was slightly longer in the DM group, but not statistically significant (2.9 versus 2.6 days, respectively). In the DM group, 1 patient stayed for 13 days because of severe portsite infection, which required return to the operating room for incision and drainage. Another patient stayed for 9 days because of exacerbation of carpal tunnel syndrome. One patient in the DM group developed early pyelonephritis, and another patient with type 1 DM developed diabetic ketoacidosis. Two patients in the non-DM group underwent reoperation within 30 days postoperatively. One patient developed an incarcerated port-site hernia, which required laparoscopic exploration and hernia repair during the same hospital admission. Another patient had an inadvertently sutured nasogastric tube during the creation of the duodenojejunostomy, which required endoscopic release in the operating room on postoperative day 1 [11]. Other 30-day postoperative complications in the non-DM group included hospital-acquired pneumonia and urosepsis related to obstructing kidney stones. All in the DM group, except 2 patients (96%), no longer required insulin to control their blood glucose immediately following the operation. Fingerstick blood glucose measurements were performed by the nursing staff every 6 hours during the postoperative phase until discharge from the
3
hospital. One patient with type 1 DM required subcutaneous insulin injection for glucose control, postoperatively. She made an uneventful recovery and was finally discharged home on one-third of the preoperative insulin dose. Another patient in the DM group temporarily required low-dose insulin on postoperative day 1. On postoperative day 2, her blood sugar stabilized, and she no longer required insulin. All oral antidiabetic agents were permanently discontinued after BPD/DS. The average excess weight loss was higher in the DM group at 1 month. The average percentage of excess weight loss (%EWL) for the DM and non-DM groups at 1 month was 20.9 and 17.9, respectively. The %EWL was comparable at 3, 6, 9, 12, and 18 months (Table 2, Fig. 1). The rate of follow-up was a 100% at 1, 3, and 6 months, 92% at 9 and 12 months, and 85.4% at 18 months.
Discussion It has been well established that bariatric surgery is more effective in achieving initial as well as long-term weight loss compared with conventional medical therapy alone. The mechanism of resolution of T2 DM following bariatric surgery for malabsorption has not been completely understood; it is unlikely to be only attributed to the decreased caloric intake because improved glucose control can be as early as few hours postoperatively. Guidone et al. studied the pathophysiologic mechanisms of rapid resolution of T2 DM in 10 obese patients who underwent BDP/DS [12]. Their study showed decrease in plasma concentration of glucose-dependent insulinotropic polypeptide, which is secreted by the duodenum, and elevation in plasma level of glucagon-like peptide-1, which is secreted by the distal small bowel. These changes ultimately cause improvement of beta-cell sensitivity to glucose and reduction of peripheral insulin resistance. BPD/DS is currently the most effective bariatric operation for weight loss as well as resolution of obesity-related metabolic co-morbidities, such as DM, hypertension, and hyperlipidemia [3]. Cho et al. reported that overall 91% of BPD/DS patients achieved resolution of DM postoperatively, with complete resolution of DM in all patients who had been on oral antidiabetics or on insulin for o 5 years Table 2 Excess weight loss outcome after BPD/DS Group
1 month
3 months
6 months
9 months
12 months
18 months
I (DM) % II (non-DM) % P value
20.9 17.9
37.1 35.6
53.9 53.1
64.8 66.4
73.6 75.7
80.1 81.2
.0
.4
.8
.6
.6
.8
BPD/DS ¼ Biliopancreatic diversion with duodenal switch; DM ¼ diabetes mellitus.
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M. Abulfaraj et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
BPD/DS = Biliopancreatic Diversion with Duodenal Switch DM = Diabetes Mellitus
Fig. 1. Comparison of weight loss outcome after biliopancreatic diversion with duodenal switch (BPD/DS).
[4]. The resolution of DM in those who undergo BPD/DS is significantly higher than in those who undergo gastric bypass (84%) or adjustable gastric banding (48%) [13]. A previously described drawback of RYGB is the suboptimal weight loss in certain groups of patients [5–9]. Factors that have been reported to contribute to this phenomenon include black race, male gender, marriage, older age, greater initial weight, open approach, larger pouch, and DM status [5,8,14,15]. However, after multivariate analysis, the only 2 remaining factors that were independently associated with poor weight loss were large gastric pouch size and DM status. Patients with DM controlled using insulin rather than oral antihyperglycemics were at a particularly greater disadvantage, experiencing even less postoperative weight loss. Campos et al. reported that 12.3% of patients with DM had poor %EWL, whereas only 8.2% of patients without DM had poor %EWL. Among the patients with DM who had poor %EWL, 18.4% were on oral antihyperglycemic agents and 22.2% were on insulin regiments [8]. It is possible that the suboptimal postoperative weight loss after RYGB in patients with DM is related to a higher degree of insulin resistance; therefore, they require higher circulating levels of insulin to achieve glucose homeostasis. As insulin itself is an anabolic hormone, it may be one of many factors contributing to suboptimal postoperative weight loss [16]. The United Kingdom Prospective Diabetes Study (UKPDS) described that, although treatment of DM using insulin may cause fewer microvascular complications,
it may inadvertently promote weight gain related to its anabolic effect [17]. In our study, the discrepancy in preoperative BMI between the DM and non-DM groups was likely because the patients with DM were more likely to be advised to have operations for malabsorption (i.e., BPD/DS or RYGB) despite having lower BMI (35–50 kg/m2). In our study, morbidly obese patients with severely elevated HgA1c (410) were advised to undergo BPD/DS despite their BMI being o50 kg/m2. In our bariatric program, with a close and aggressive follow-up protocol, we have not seen long-term severe malnutrition problems as typically described after BPD/DS. Of the 152 patients who underwent BPD/DS at our institution, at 1 month postoperatively, the DM group had a higher %EWL (20.9%) compared with the non-DM group (17.9%). At 3, 6, 9, 12, and 18 months postoperatively, both groups had comparable %EWL. Therefore, unlike the suboptimal weight loss seen in patients with DM who underwent RYGB in other studies, those who underwent BPD/DS achieved excellent postoperative weight loss, comparable with that in patients without DM. The suboptimal weight loss in gastric bypass patients with DM should theoretically still apply to those who underwent BPD/DS; however; the weight loss outcome is clearly not similar. Therefore, morbidly obese patients with T2 DM have a potentially greater benefit from BPD/ DS compared with RYGB. Additionally, they were shown to have equivalent postoperative weight loss compared with those without T2 DM.
Preoperative Diabetes Mellitus and Weight Loss Outcome / Surgery for Obesity and Related Diseases ] (2015) 00–00
Conclusion Even though DM status has previously been reported as an independent predictor for suboptimal weight loss after RYGB, it does not predict weight loss outcome after BPD/ DS. Patients with DM who undergo BPD/DS achieve a higher %EWL at 1 month postoperatively compared with those without DM. At 3, 6, 9, 12, and 18 months after BPD/ DS, patients with or without DM achieve similar %EWL. References [1] Scopinaro N, Gianetta E, Civalleri D. Bilio-pancreatic bypass for obesity: II. Initial experience in man. Br J Surg 1979;66(9):618–20. [2] Marceau P, Biron S, Bourque RA. Biliopancreatic diversion with a new type of gastrectomy. Obes Surg 1993;3(1):29–35. [3] Dorman RB, Rasmus NF, al-Haddad BJ. Benefits and complications of the duodenal switch/biliopancreatic diversion compared to the Roux-enY gastric bypass. Surgery 2012;152(4):758–65, discussion 765–67. [4] Cho EY, Kemmet O, Frenken M, et al. Biliopancreatic diversion with duodenal switch in patients with type 2 diabetes mellitus: is the chance of complete remission dependent on therapy and duration of insulin treatment? Obes Facts 2011;4(Suppl 1):18–23. [5] Ma Y, Pagoto SL, Olendzki BC, et al. Predictors of weight status following laparoscopic gastric bypass. Obes Surg 2006;16(9):1227–31. [6] Carbonell AM, Wolfe LG, Meador JG. Does diabetes affect weight loss after gastric bypass? Surg Obes Relat Dis 2008;4(3):441–4. [7] Júnior WS, do Amaral JL, Nonino-Borges CB. Factors related to weight loss up to 4 years after bariatric surgery. Obes Surg 2011;21 (11):1724–30.
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[8] Campos GM, Rabl C, Mulligan K, et al. Factors associated with weight loss after gastric bypass. Arch Surg 2008;143(9):877–84. [9] Melton GB, Steele KE, Schweitzer MA. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes. J Gastrointest Surg 2008;12 (2):250–5. [10] National Institutes of Health. Gastrointestinal surgery for severe obesity: Consensus Development Conference Panel. Ann Intern Med 1991;115(12):956–61. [11] Sucandy I, Antanavicius G. A novel use of endoscopic cutter: endoscopic retrieval of a retained nasogastric tube following a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch. N Am J Med Sci 2011;3(10):486–8. [12] Guidone C, Manco M, Valera-Mora E. Mechanisms of recovery from type 2 diabetes after malabsorptive bariatric surgery. Diabetes 2006;55(7):2025–31. [13] Buchwald H, Estok R, Fahrbach K. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009;122(3):248–56. [14] Lutfi R, Torquati A, Sekhar N. Predictors of success after laparoscopic gastric bypass: a multivariate analysis of socioeconomic factors. Surg Endosc. 2006;20(6):864–7. [15] Melton GB, Steele KE, Schweitzer MA, et al. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes. J Gastrointest Surg 2008;12 (2):250–5. [16] Flier J, Maratos-Flier E. Energy homeostasis and body weight. Curr Biol 2000;10(6):R215–7. [17] Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352(9131):837–53.