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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses the pathophysiology of bariatric surgery, which includes hybrid of Roux-En-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD). Also discussed are the methods and results of bariatric surgery.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes Mellitus\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EObesity\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes Mellitus\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EObesity\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EEndocrinology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes \u0026amp; Metabolic Syndrome\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EEle Ferrannini, MD, University of Pisa School of Medicine, Pisa, Italy, discussed the pathophysiology of bariatric surgery, which he described as a hybrid of Roux-En-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD).\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EOne possible explanation for the improvement in insulin resistance with RYGB is the \u201cforegut hypothesis\u201d, which posits that the exclusion of the duodenum removes the release of a factor(s) that antagonizes insulin sensitivity.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EHowever, the available data do not support the foregut hypothesis and the involvement of weight-independent effects with respect to insulin resistance with RYGB. In morbidly obese patients, this operation improves liver, adipose tissue, and muscle insulin sensitivity essentially in proportion to weight loss. Early after surgery calorie deprivation decreases endogenous glucose release and plasma glucose levels. On the other hand, both early and late after RYGB \u03b2-cell function improves as a result of the augmented release of gut hormones (principally, glucagon-like peptide-1 [GLP-1]) that potentiate insulin secretion as well as the abatement of glucotoxicity [Camastra S et al. \u003Cem\u003EDiabetologia\u003C\/em\u003E 2011; Bradley D et al. \u003Cem\u003EJ Clin Invest\u003C\/em\u003E 2012; Lingvay I et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EFurthermore, it has been demonstrated that in response to a mixed meal, gastric bypass creates a state of improved peripheral insulin sensitivity but impaired hepatic response to a meal because of changes in the prehepatic insulin-to-glucagon ratio [Camastra S et al. \u003Cem\u003EDiabetes\u003C\/em\u003E 2013] Diabetes remission (or nonremission) may depend on the initial degree of \u03b2-cell dysfunction, rather than on insulin sensitivity, although confirmation will require studies in larger numbers of patients. [Nannipieri M et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EIn BPD, the \u201chindgut hypothesis\u201d posits that ileal mucosal cells releases factor(s) that enhance the action of insulin and that the surgical diversion elicits weight-independent effects. Results from a number of studies indicate that in morbidly obese patients, BPD normalizes insulin sensitivity and this effect occurs prior to significant post-surgery weight loss [Camastra S et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2007; Astiarraga B et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003ERegarding the foregut and hindgut hypotheses, several conclusions can be drawn:\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n            \u003Cp id=\u0022p-8\u0022\u003EBypassing the duodenum and initial jejunum does not involve metabolic mechanisms impacting on insulin resistance\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n            \u003Cp id=\u0022p-9\u0022\u003EContact of biliopancreatic secretions with the mucosa of the terminal ileum improves insulin sensitivity in a partially weight-independent manner\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n            \u003Cp id=\u0022p-10\u0022\u003EThe weight of evidence supports the hindgut hypothesis over the foregut hypothesis\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-11\u0022\u003EDimitrios Pournaras, MD, Musgrove Park Hospital, Tauton, England, United Kingdom, discussed the methods and results of bariatric surgery. The surgery is done as a means of diabetes control in the morbidly obese, with the aims of extending lifespan and improving quality of life. The principle aim of bariatric surgery in these patients is not strictly weight loss.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EThe approach is safe. Exemplifying this, \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E summarizes data of 5612 patients from the National Bariatric Surgery Registry for 2012 in the United Kingdom for 3 types of bariatric surgery. The in-hospital mortality rate was very low.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13814\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13814\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13814\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003EOutcomes in the 2012 UK National Bariatric Surgery Registry\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-14\u0022\u003EThe safety of bariatric surgery is especially bolstered when performed in a facility with high volume experience. Despite this, bariatric surgery performed in the morbidly obese should not be regarded as a means of achieving complete remission of diabetes, which is defined as a glycated hemoglobin (HbA1C) level \u0026lt;6% and fasting glucose \u0026lt;5.6 mmol\/L for at least 1 year after surgery, and no active hypoglycemic pharmacologic therapy or ongoing procedures [Buse JB et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2009]. However, the procedures are excellent in achieving glycemic control (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E) [Pournaras DJ et al. \u003Cem\u003EBrit J Surg\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13815\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13815\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13815\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003EGlycemic Control Following Bariatric Surgery\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-17\u0022\u003EA number of randomized controlled trials have demonstrated the ability of bariatric surgery to produce long-term reductions in HbA1C. One trial randomized 60 patients with type 2 diabetes mellitus (T2DM; body mass index [BMI] \u226535 kg\/m\u003Csup\u003E2\u003C\/sup\u003E) to medical therapy, gastric bypass, or BPD. The change in HbA1C from randomization to 24 months was assessed to determine diabetes remission. All 3 treatments produced an initial drop in HbA1C in the first 3 months with a subsequent plateau at marginally higher or lower levels. The overall decrease in HbA1C from Month 3 to Month 24 was greatest for BPD, followed by gastric bypass and then medical therapy [Mingrone G et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012]. Another trial that randomized 150 patients (BMI 27\u201343 kg\/m\u003Csup\u003E2\u003C\/sup\u003E) to intensive medical therapy with or without RYGB or sleeve gastrectomy reported a significantly greater and sustained reduction in HbA1C with combined medical therapy and surgery [Schauer PR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EAnother option for patients with T2DM and obesity is implanting an impermeable duodenal-jejunal bypass liner. A study involving 16 patients with T2DM reported a lower HbA1C with the liner at 52 weeks compared with no liner (7.5\u00b10.4% vs 8.6\u00b10.2%; p\u0026lt;0.001) [Cohen R et al. \u003Cem\u003EDiabet Med\u003C\/em\u003E 2013]. The mean duration of diabetes was 2 to 10 years and HbA1C ranged between 7.5% and 10.2% at baseline. All patients were on metformin, but none were taking insulin, a GLP-1 analogue, or dipeptidyl peptidase-4 inhibitor.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EAccording to Prof. Pournaras, the collective data allow the following conclusions:\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \u003Cp id=\u0022p-20\u0022\u003EBariatic surgery is a safe weight loss approach for obese diabetics\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n            \u003Cp id=\u0022p-21\u0022\u003ERemission of T2DM is possible\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n            \u003Cp id=\u0022p-22\u0022\u003EDiabetes-related complications can be reduced\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n            \u003Cp id=\u0022p-23\u0022\u003EDiabetes can recur\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n            \u003Cp id=\u0022p-24\u0022\u003ECombinational treatment incorporating surgery can be advantageous\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n            \u003Cp id=\u0022p-25\u0022\u003EOutcome is optimized by identifying patients who will benefit most and when benefits are achieved\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/17\/34.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznlop\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nznlop\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}