Shinshu M ed J, 59 ⑷ :273〜279, 2011

Bariatric Surgery on Type 2 Diabetes Mellitus Patients in Japan
Junichiro MORI ＊, Yoshihiko SATO
Hiroaki ISHII and Mitsuhisa KOMATSU
1） Center for Medical Education, Shinshu University School of Medicine
2） Department of Aging Medicine and Geriatrics, Shinshu University Graduate School of Medicine

Key words:bariatric surgery, obesity, diabetes

Introduction

a median follow‑up period of 5.6 years .M oreover,many patients who are initially successful at weight

Amidst a worldwide epidemic of diabetes, theloss then go on to rebound . Thus, promoting

World Health Organization estimates that moreweight loss without rebound is a major issue inthan 220 million people have diabetes and an esti-

treatment, especially in severely obese patients.

mated 3.4 million people died from consequences ofRecently,there has been an increase in patients withhigh blood sugar in 2004 . In Japan, a 2009 reporta BMI＞35 undergoing bariatric surgery .Bariatricfrom the M inistry of Health, Labour and Welfare

surgery generally consists of either gastric bypass,stated that there are approximately 8.9 million

as typiﬁed by the Roux‑en‑Y Gastric Bypass

Japanese who are strongly suspected of having(RYGB),or gastric binding,including vertical band-

diabetes . Over time, diabetes can damage theed gastroplasty and laparoscopic adjustable gastricheart, blood vessels, eyes, kidneys, and nerves. In

banding. The RYGB method creates a proximal

particular, diabetes increases the risk of heart dis-pouch by segmentation of the stomach and theease and stroke.

proximal pouch is drained with a Roux limb of

Obesity carries with it signiﬁcant risks ofproximal jejunum . Vertical banded gastroplasty

diabetes .Improvement in obesity is attendant withfeatures a small pouch based on the lesser curvature

improvements in this ailment , and obese peopleof the stomach and a mesh or plastic band aroundconsequently have been treated through phar-the outlet of the pouch to narrow the outlet to aboutmacotherapy,and intervention in life habits,includ-

1 cm . Laparoscopic adjustable gastric banding is

ing diet and exercise. Even with such treatment,

similar to vertical banding but uses an adjustablehowever, it is very diﬃcult to achieve satisfactoryband,which is lined with an inﬂatable cuﬀjoined tobody weight loss.In the last few years many studies

a small reservoir to allow adjustment of the pouch

have been performed to compare intensive glucose

outﬂow and meal capacity . There has been acontrol therapy with standard therapy.M ost of thenotable increase in studies describing the eﬀect of

results show that body weight did not change withbariatric surgery on type 2 diabetes patients .

either intensive glucose control therapy or standard
therapy .Additionally,in the case of the VeteransAﬀairs Diabetes Trial (VADT), body mass index

Eﬀect of Bariatric Surgery on Obesity
and Diabetes(BMI)of the patients increased from 31.3 kg/m toAlthough an average of 55.9 % loss in excess body33.8 kg/m with intensive glucose control therapy inweight was observed in bariatric surgery , theextent of operation‑induced weight loss varies de-Corresponding author:Junichiro Mori
Center for M edical Education,Shinshu University School

pending on the surgical method . Gastric bindingof M edicine, 3‑1‑1 Asahi, M atsumoto‑city,

reduce the storage capacity of the stomach and as a

Nagano‑prefecture 390‑8621, Japan

result early satiety arises, leading to a decreased

No. 4, 2011273

M ori.Sato.Ishii et al.
Table 1

Eﬃcacy for improvement in diabetes‑related outcomes for diabetic andglucose‑intolerant patients

Absolute Weight Loss (Kg)
BM I Decrease (kg/m )Excess Loss (%)
Fasting Insulin (pmol/L)
HbA1c (%)
Fasting Glucose (mmol/L)

Total (n)Gastric Binding (n)Gastric Bypass (n)‑41.9 (266)‑14.0 (306)‑57.3 (267)‑123.9 (160)‑2.4 (171)‑26.0 (56)‑9.1 (56)‑41.0 (83)‑49.5 (56)‑1.2 (83)‑50.54 (129)‑18.0 (166)‑65.7 (184)‑153.7 (90)‑3.0 (88)‑4.0 (296)‑3.2 (56)‑3.4 (164)

BMI :body mass index

caloric intake . RYGB also has this aspect but in

GLP‑1 is also involved in the proliferation andaddition it shortens the functional length of theregeneration of pancreatic β‑cells

small intestine and creates a short‑bowel syn-been numerous studies detailing a post‑operativedrome . While loss in body weight from interven-increase in GLP‑1 secretion from gastric bypass,tion in life habits is insuﬃcientand this increase occurs prior to post‑gastric bypass, it was 46.2%. There have.Studies show that the post‑gastricfor gastric binding and 59.5% for gastric bypass,

weight loss

respectively, thus showing that bariatric surgery

bypass GLP‑1 level is signiﬁcantly higher whenleads to more eﬃcient weight‑loss results . How-

compared to the post‑gastric binding GLP‑1

ever,although bariatric surgery generally leads to alevel

great improvement in diabetes(Table 1), there is

GLP‑1 level is signiﬁcantly higher in post‑gastrica gradation of results depending on the procedure .

bypass groups than in groups reducing their weight

Additionally for type 2 diabetes patients,studies on

through diet and/or medication

gastric bypass have shown that improvements in

is no statistical diﬀerence in post‑operative bodyfasting plasma glucose and insulin sensitivity areweight based on surgical methods according toevident prior to weight loss

these studies, it seems that the change in body

. These kinds of. There are also studies showing that the. Because there.

weight is not the primary factor modulating GLP‑1

From these results, apart from improvements inin gastric bypass. Based on the food stimulation‑

insulin sensitivity induced through weight loss,gas-induced secretion from the distal ileum, sometric bypass is also thought to improve glucose

groups think that increases in GLP‑1 secretion after

metabolism.

the gastric bypass can be attributed to the phenome-changes are not observed in gastric binding

non whereby the post‑operative gut forms in such a

Eﬀects of Bariatric Surgery on

way that dense foods pass rapidly into the distal

Intestinal Hormones

intestine.As no improvement occurs in fasting

One hypothesis to explain this phenomenon is theplasma glucose in cases in which food is made toinﬂuence of gastrointestinal hormones. Glucagon‑

pass via both the duodenum and the stomach‑small

like peptide‑1 (GLP‑1), an intestinal hormone se-intestine shunt, an alternative hypothesis is thatcreted from the distal ileum and colon in response tofood passing via the proximal intestine exerts anutrient ingestion ,increases c‑AM P in pancreatic

negative inﬂuence on glucose metabolism

β‑cells and is involved in glucose‑dependent insulin

considering the eﬀect of GLP‑1, it is possible that

. GLP‑1 decreases dietary intake by

the increase in endogenous GLP‑1 secretion plays

releaseslowing gastric emptyingof gastric acid, controlling secretionand glucagon , and inducing sati-

ety by working on the central nervous system
274

.

.When

an important role in the improvement of glucose
metabolism by the gastric bypass surgery.
Although ghrelin is similar to GLP‑1 in that it is
Shinshu Med J Vol.59

Bariatric surgery on type 2 diabetes mellitus patients in Japan
Table 2 Complications from bariatric surgery
RYGB (Studies/Patients) VBG (Studies/Patients) AGB (Studies/Patients)% Early or time‑unspeciﬁed
mortality Rate

1.0(15/907)

0.2(11/401)

0.4(6/268)

16.9 (34/7374)
10.9 (3/727)
15.7(8/1324)

17.5(21/1692)
2.2(7/823)
18.4(10/1177)

7.0(17/3400)
4.7(4/485)
2.5(4/562)

16.9 (10/2088)
4.6(30/5645)
2.0(19 /5026)
1.6(9 /4356)

2.5(4/397)
6.0(14/1456)
0.7(6/1027)
11.3(7/520)

NRNR
0.3(6/2844)
7.7(11/2140)

GI Symptoms% All% Reﬂux% Vomiting% Nutritional and electrolyte
abnormalities% Anatomic or Stromal Stenosis% Bleeding% Reoperation

RYGB :Roux‑en‑Y Gastric Bypass, VBG :Vertical Banded Gastroplasty, AGB :Adjustable Gastric Band,NR :not reported

related to the appetite, it is actually an appetite‑
stimulating hormone.It is likely that the appe-tite stimulation from ghrelin is due to its increasing
activity in the stomach

Adverse Eﬀects of Bariatric Surgery
There are some complications from bariatricand suppression of insu-

surgery that occur solely from its nature as surgery.

lin secretion . Ghrelin levels increase in dietary

In addition to the post‑operative short‑term mortal-

restriction‑induced weight loss and when there is aity rates (deaths within 30 days post‑surgery) ofnegative energy balance ,and conversely,decrease

0.2% in the case of VBG and 1.0% in the case of thewhen eating or in the case of the obese .However

potentially more eﬀective RYGB , complicationsin the case of the obese, ghrelin levels become

other than death have been reported as follows:GI

unchanged even when eating,and therefore,ghrelin

symptoms in 16.9 % of RYGB cases and 17.5% oflevel is a potential factor in obesity . There are

VBG cases, and nutritional and electrolyte abnor-

many reports of postprandial, post‑RYGB ghrelin

malities in 16.9 % for RYGB and 2.5% for VBG

levels and ghrelin levels decreasing in times of(Table 2) .

fasting compared to pre‑operation
normal body weight, obese, lean,, and post‑sur-gery in other types of bariatric surgery.How-

Clinical Application of Bariatric Surgery
in Japanever, there are also studies showing that postpran-

As previously stated, there are reports that bar-dial, post‑RYGB ghrelin levels are comparable toiatric surgery leads to dramatic improvement inthose of lean and post‑surgery patients in othertype 2 diabetes compared to pharmacotherapy andkinds of bariatric surgery. It has been reported

lifestyle intervention‑based treatment. Will bar-that a decrease in ghrelin levels occurs immediately

iatric surgery replace conventional medication and/following surgery and lasts for more than aor life style intervention‑based treatment in Japan?

year. Through RYGB, food bypasses the distal

At present, however, most of these reports are notstomach in which ghrelin is released, and this may

necessarily targeting regular subjects, given theaccount for the post‑bypass decrease in ghrelinsubjectsʼextremely high average BM I of 47.9 kg/m

levels . This explanation would suggest the possi-

and relatively young average age of 40.2 years old.

bilitythat appetite cannot be suppressed in bariatricObesity in the Japanese population is much lesssurgery that does not bypass the distal stomach.

than in Western populations. The Ministry of
Health, Labour and Welfare, Japan reported thatNo. 4, 2011275

M ori.Sato.Ishii et al.

only 3.7% of the population is obese (BM I＞30) .

weight‑loss results.Bariatric surgery is an eﬀective

The rate of obesity in diabetes is reported to betreatment option for severely obese patients for

similar to that in the rest of the Japanese popula-whom weight loss has been problematic with con-tion , and at present bariatric surgery has only aventional pharmacotherapy and/or life style inter-

limited application in Japan.

vention‑based treatment. At present, however,there is a need for a high‑evidence level cohort

Summary

study based on previous research that varies by age

In this review, we outlined the endocrinologicaland obesity level in order to further the discussion

and clinical eﬀects of bariatric surgery in obese andon whether bariatric surgery should be given prece-

diabetic patients. Recently, in certain countries,

dence over conventional medication and life style

there has been an increase in obese patients under-intervention‑based treatment in Japan.

going bariatric surgerywhich leads to more eﬃcient
References
1) World Health Organization :Diabetes. Fact sheet No312, Geneva, 20112) M inistry of Health, Labour and Welfare, Japan :National Health and Nutrition examination 2009. Tokyo, 20103) M okdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS :Prevalence of obesity diabetes
and obesity‑related health risk factors 2001. JAM A 289 :76‑79, 2003
4) Pi‑Sunyer X, Blackburn G, Brancati FL, Bray GA, Bright R, Clark JM , Curtis JM , Espeland M A, Foreyt JP,
Graves K, Haﬀner SM, Harrison B, Hill JO, Horton ES, Jakicic J, Jeﬀery RW, Johnson KC,Kahn S,Kelley DE,
Kitabchi AE, Knowler WC, Lewis CE, M aschak‑Carey BJ, M ontgomery B, Nathan DM, Patricio J, Peters A,
Redmon JB, Reeves RS, Ryan DH, Saﬀord M, Van Dorsten B, Wadden TA,Wagenknecht L,Wesche‑Thobaben
J, Wing RR, Yonavski SZ :Reduction in weight and cardiovascular disease risk factors in individuals with type2 diabetes:one‑year results of the look AHEAD trial. Diabetes Care 30:1374‑1383, 2007
5) Espeland M A, Bray GA, Neiberg R, Rejeski WJ, Knowler WC, Lang W, Cheskin LD, Williamson D, Lewis CB,
Wing R :Describing patterns of weight changes using principal components analysis:results from the Action for
Health in Diabetes (Look AHEAD)research group. Ann Epidemiol 19 :701‑710, 2009
6) Patel A,M acMahon S,Chalmers J,Neal B,Billot L,Woodward M ,M arre M ,Cooper M,Glasziou P,Grobbee D,
Hamet P,Harrap S,Heller S,Liu L,Mancia G,Mogensen CE,Pan C,Poulter N,Rodgers A,Williams B,Bompoint
S,de Galan BE,Joshi R,Travert F :Intensive blood glucose control and vascular outcomes in patients with type2 diabetes. N Engl J Med 358:2560‑2572, 2008
7) Gerstein HC, M iller ME, Genuth S, Ismail‑Beigi F, Buse JB, GoﬀDC Jr, Probstﬁeld JL, Cushman WC, Ginsberg
HN, Bigger JT, Grimm RH Jr, Byington RP, Rosenberg YD, Friedewald WT :Long‑term eﬀects of intensive
glucose lowering on cardiovascular outcomes. N Engl J Med 364:818‑828, 20118) Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, Zieve FJ, Marks J, Davis SN, Hayward
R, Warren SR, Goldman S, McCarren M , Vitek ME, Henderson WG, Huang GD :Glucose control and vascularcomplications in veterans with type 2 diabetes. N Engl J Med 360:129 ‑139, 20099) Buchwald H, Estok R, Fahrbach K, Banel D, Jensen M D, Pories WJ, Bantle JP, Sledge I :Weight and type 2
diabetes after bariatric surgery:systematic review and meta‑analysis. Am J M ed 122:248‑256, 200910) Pories WJ :Bariatric surgery:risks and rewards:J Clin Endocrinol Metab 93:S89 ‑S96, 2008
11) Garb J,Welch G,Zagarins S,Kuhn J,Romanelli J :Bariatric surgery for the treatment of morbid obesity:a meta‑
analysis of weight loss outcomes for laparoscopic adjustable gastric banding and laparoscopic gastric bypass.Obes
Surg 19 :1447‑1455, 200912) Schneider BE, M un EC :Surgical management of morbid obesity. Diabetes Care 28:475‑480, 2005
276

Shinshu Med J Vol.59

Bariatric surgery on type 2 diabetes mellitus patients in Japan
13) Santry HP, Gillen DL, Lauderdale DS :Trends in bariatric surgical procedures. JAM A 19 :1909 ‑1917, 200514) Sjostrom CD, Peltonen M, Wede H, Sjostrom L :Diﬀerentiated long‑term eﬀects of intentional weight loss on
diabetes and hypertension. Hypertension 36:20‑25, 2000
15) Knowler WC, Barrett‑Connor E, Fowler SE,Hamman F,Lachin JM,Walker EA,Nathan DM :Reduction in theincidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J M ed 346:393‑403, 200216) Buchwald H, Avidor Y, Braunwald E, Jensen M D, Pories K, Fahrbach K, Schoelles K : Bariatric surgery: asystematic review and meta‑analysis. JAM A 292:1724‑1737, 200417) Pournaras DJ, LeRoux CW :The eﬀect of bariatric surgery on gut hormones that alter appetite.Diabetes M etab
35:508‑512, 200918) Bose M , Teixeira J, Olivan B, Bawa B, Arias S, M achineni S, Pi‑Sunyer FX, Scherer PE, Laferrere B :Weightloss and incretin responsiveness improve glucose control independently after gastric bypass surgery.J Diabetes 2:
47‑55, 200919) Bikman BT, Zheng D, Pories WJ, Chapman W, Pender JR, Bowden RC, Reed M A, Cortright RN, Tapscott EB,
Houmard JA, Tanner CJ, Lee J, Dohm GL : Mechanism for improved insulin sensitivity after gastric bypass
surgery. J Clin Endocrinol M etab 93:4656‑4663, 200820) Vincent RP, leRoux CW :Changes in gut hormones after bariatric surgery. Clin Endocrinol 69 :173‑179, 200821) Giorgino F, Natalicchio A, Leonardini A, Laviola L : Exploiting the pleiotropic actions of GLP‑1 for the
management of type 2 diabetes mellitus and its complication. Diabetes Res Clin Pract 78:S59 ‑S67, 200722) Edholm T, Degerblad M, Gryback P, Hilsted L, Holst JJ, Jacobsson H, Efendic S, Schmidt PT, Hellstrom PM :Diﬀerential incretin eﬀects of GIP and GLP‑1 on gastric emptying, appetite and insulin‑glucose homeostasis.
Neurogastroenterol Motil 22:1191‑1200, 201023) Nauck MA, Niedereichholz U, Ettler R, Holst JJ, Orskov C, Ritzel R, Schmiegel WH :Glucagon‑like peptide 1
inhibition of gastric emptying outweighs its insulinotropic eﬀects in healthy humans.Am J Physil 273:E981‑E988,
199724) Asmar M , Bache M, Knop FK, Madsbad S, Holst JJ : Do the actions of glucagon‑like peptide‑1 on gastric
emptying,appetite,and food intake involve release of amylin in humans?J Clin Endocrinol M etab 95:2367‑2375,
201025) Jayasena CN, Bloom SR :Role of gut hormones in obesity. Endocrinol M etab Clin North Am 37:769 ‑787, 200826) M a X, Bruning J, Ashcroft FM :Glucagon‑like peptide 1 stimulates hypothalamic proopiomelanocortin neurons.
J Neurosci 27:7125‑7129, 200727) Pannacciulli N, Le DS, Salbe AD, Chen K, Reiman EM, Tataranni PA, Krakoﬀ J :Postprandial glucagon‑like
peptide‑1 (GLP‑1)response is positively associated with changes in neuronal activity of brain areas implicated insatiety and food intake regulation in humans. Neuroimage 35:511‑517, 200728) Holst JJ :The physiology of glucagon‑like peptide 1. Physiol Rev 87:1409 ‑1439, 200729) Buteau J, Roduit R, Susini S, Prentki M : Glucagon‑like peptide‑1 promotes DNA synthesis, activates phosphatidylinositol 3‑kinase and increases transcription factor pancreatic and duodenal homeobox gene 1 (PDX‑1)
DNA binding activity in beta (INS‑1)‑cells. Diabetologia 42:856‑864, 199930) M acDonald PE, El‑Kholy W, Riedel MJ, Salapatek AM, Light PE, Wheeler MB :The multiple actions of GLP‑
1 on the process of glucose‑stimulated insulin secretion. Diabetes 51:S434‑S442, 200231) Goldﬁne AB,M un EC,Devine E,Bernier R,Baz‑Hecht M ,Jones DB,Schneider BE,Holst JJ,Patti M E : Patientswith neuroglycopenia after gastric bypass surgery have exaggerated incretin and insulin secretory responses to amixed meal. J Clin Endocrinol Metab 92:4678‑4685, 200732) LeRoux CW,Aylwin SJ,Batterham RL,Borg CM ,Coyle F,Prasad V,Shurey S,Ghatei MA,Patel AG,Bloom SR :Gut hormone proﬁles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve
No. 4, 2011277

M ori.Sato.Ishii et al.
metabolic parameters. Ann Surg 243:108‑114, 200633) M orinigo R,Moize V,Musri M,Lacy AM,Navarro S,M arin JL,Delgado S,Casamitjana R,Vidal J :Glucagon‑
like peptide‑1, peptide YY, hunger, and satiety after gastric bypass surgery in morbidly obese subjects. J Clin
Endocrinol Metab 91:1735‑1740, 2006
34) Korner J,Bessler M,Inabnet W,Taveras C,Holst JJ :Exaggerated glucagon‑like peptide‑1 and blunted glucose‑dependent insulinotropic peptide secretion are associated with Roux‑en‑Y gastric bypass but not adjustable
gastric banding. Surg Obes Relat Dis 3:597‑601, 200735) Rodieux F, Giusti V, Dʼ
Alessio DA, Suter M, Tappy L :Eﬀects of gastric bypass and gastric banding on glucose
kinetics and gut hormone release. Obesity (Silver Spring)16:298‑305, 2008
36) Rubino F, Gagner M, Gentileschi P, Kini S, Fukuyama S, Feng J, Diamond E :The early eﬀect of the Roux‑en‑
Y gastric bypass on hormones involved in body weight regulation and glucose metabolism.Ann Surg 240:236‑242,
200437) Rubino F,Forgione A,Cummings DE,Vix M,Gnuli D,Mingrone G,Castagneto M,Marescaux J :The mechanismof diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in thepathophysiology of type 2 diabetes. Ann Surg 244:741‑749, 200638) Nguyen NT, Stevens CM, Wolfe BM :Incidence and outcome of anastomotic stricture after laparoscopic gastricbypass. J Gastrointest Surg 7:997‑1003, 2003
39) Suter M , Giusti V, Heraief E, Zysset F, Calmes JM : Laparoscopic Roux‑en‑Y gastric bypass: initial 2‑year
experience. Surg Endosc 17:603‑609, 2003
40) Cooney RN,Haluck RS,Ku J,Bass T,MacLeod J,Brunner H,M iller CA :Analysis of cost outliers after gastricbypass surgery:what can we learn ?Obes Surg 13:29 ‑36, 2003
41) Rubino F :Is type 2 diabetes an operable intestinal disease?A provocative yet reasonable hypothesis. Diabetes
Care 31:S290‑S296, 2008
42) Colquitt J,Clegg A,Sidhu M,Royle P :Surgery for morbid obesity.Cochrane Database Syst Rev :CD003641,2003
43)

M urphy KG, Bloom SR :Gut hormones and the regulation of energy homeostasis. Nature 444:854‑859, 2006

44) Cummings DE, Overduin J :Gastrointestinal regulation of food intake. J Clin Invest 117:13‑23, 200745) Nakazato M, Murakami N, Date Y, Kojima M , Matsuo H, Kangawa K, M atsukura S :A role for ghrelin in thecentral regulation of feeding. Nature 409 :194‑198, 2001
46) Zwirska‑Korczala K,Konturek SJ,Sodowski M ,Wylezol M,Kuka D,Sowa P,Adamczyk‑Sowa M ,Kukla MM ,Berdowska A, Rehfeld JF, Bielanski W, Brzozowski T :Basal and postprandial plasma levels of PYY, ghrelin,cholecystokinin, gastrin and insulin in women with moderate and morbid obesity and metabolic syndrome. J
Physiol Pharmacol 58:13‑35, 200747) HansenTK, Dall R, Hosoda H, Kojima M , Kangawa K, Christiansen JS, Jorgensen JO : Weight loss increases
circulating levels of ghrelin in human obesity. Clin Endocrinol 56:203‑206, 200248) Cummings DE,Foster‑Schubert KE,Overduin J :Ghrelin and energy balance:focus on current controversies.Curr
Drug Targes 6:153‑169, 200549) English PJ, Ghatei MA,Malik IA,Bloom SR,Wilding JP :Food fails to suppress ghrelin levels in obese humans.
J Clin Endocrinol Metab 87:2984, 2002
50) Lin E,Gletsu N,Fugate K,McClusky D,Gu LH,Zhu JL,Ramshaw BJ,Papanicolaou DA,Ziegler TR,Smith CD :The eﬀects of gastric surgery on systemic ghrelin levels in the morbidly obese. Arch Surg 139 :780‑784, 2004
51) Tritos NA, M un E, Bertkau A, Grayson R, Maratos‑Flier E, Goldﬁne A : Serum ghrelin levels in response to
glucose load in obese subjects post‑gastric bypass surgery. Obes Res 11:919 ‑924, 2003
52) Chan JL,M un EC,Stoyneva V,M antzoros CS,Goldﬁne AB :Peptide YY levels are elevated after gastric bypass
surgery. Obesity (Silver Spring)14:194‑198, 2006
278

Shinshu Med J Vol.59

Bariatric surgery on type 2 diabetes mellitus patients in Japan53) Cummings DE, Weigle DS, Frayo RS, Breen PA, Ma M K, Dellinger EP, Purnell JQ :Plasma ghrelin levels after
diet‑induced weight loss or gastric bypass surgery. N Engl J Med 346:1623‑1630, 2002
54) Leonetti F,Silecchia G,Iacobellis G,Ribaudo MC,Zappaterreno A,Tiberti C,Iannucci CV,Perrotta N,Bacci V,
Basso M S,Basso N,DiMario U :Diﬀerent plasma ghrelin levels after laparoscopic gastric bypass and adjustable
gastric banding in morbid obese subjects. J Clin Endocrinol Metab 88:4227‑4231, 2003
55) Engstrom BE,Ohrvall M,Sundbom M,Lind L,Karlsson FA :Meal suppression ofcirculating ghrelin is normalized
in obese individuals following gastric bypass surgery. Int J Obes 31:476‑780, 200756) Korner J, Inabnet W, Conwell IM , Taveras C, Daud A, Olivero‑Rivera L, Restuccia NL, Bessle M :Diﬀerential
eﬀects of gastric bypass and banding on circulating gut hormone and leptin levels.Obesity(Silver Spring)14:1553‑
1561, 2006
57) Korner J, Bessler M , Cirilo LJ, Conwell IM , Daud A, Restuccia NL, Wardlaw SL :Eﬀects of Roux‑en‑Y gastricbypass surgery on fasting and postprandial concentrations of plasma ghrelin, peptide YY, and insulin. J Clin
Endocrinol Metab 90:359 ‑365, 2005
58) LeRoux CW,Welbourn R,Werling M,Osborne A,Kokkinos A,Laurenius A,Lonroth H,Fandriks L,Ghatei MA,
Bloom SR,Olber T :Gut hormones as mediators of appetite and weight loss after Roux‑en‑Y gastric bypass.Ann
Surg 246:780‑785, 200759) M aggard MA,Shugarman LR,Suttorp M,M aglione M ,Sugerman HJ,Livingston EH,Nguyen NT,Li Z,M ojica
WA,Hilton L,Rhodes S,Morton SC,Shekelle PG :M eta‑analysis:surgical treatment of obesity.Ann Intern Med
142:547‑559, 200560) M inistry of Health, Labour and Welfare, Japan :Outline of the diabetes mellitus ﬁeld study 2002. Tokyo, 2004
61) Sone H, M izuno S, Fujii H, Yoshimura Y, Yamasaki Y, Ishibashi S, Katayama S, Saito Y, Ito H, Ohashi Y,
Akanuma Y, Yamada N :Is the diagnosis of metabolic syndrome useful for predicting cardiovascular disease in
Asian diabetic patients?Analysis from the Japan Diabetes Complications Study.Diabetes Care 28:1463‑1471,2005（2011. 1.27 received ; 2011. 5. 2 accepted）

No. 4, 2011279