Glycative Stress Research
Online edition : ISSN 2188-3610
Print edition : ISSN 2188-3602
Received : December 6, 2017
Accepted : January 10, 2018
Published online : March 31, 2018

Original article: Case report

A case with juvenile-onset and standard medical therapy resistant obesity
associated with type 2 diabetes undergoing laparoscopic sleeve gastrectomy
Shingo Iwata 1, 2), Akeo Hagiwara 2), Hitosi Kato 1), Keiichiro Nakamae 3), Junji Fujikura 4),
Nobuya Inagaki 4)1) Department of Surgery, Takeda General Hospital, Kyoto, Japan
2) Faculty of Life and Medical Sciences, Doshisha University, Kyoto, Japan
3) Department of Diabetes and Endocrinology, Takeda General Hospital, Kyoto, Japan
4) Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan

Abstract

A case of juvenile-onset morbid obesity with type 2 diabetes was studied; with a body mass index (BMI): 46.7 kg/m 2 andHbAlc: 9.8%. The patient underwent medical therapy over ten years but did not improve due to severe therapy resistantobesity. The application of a surgical treatment was considered. The patient had mental, psychological and social problems.
Thus, when conducting a psychological test, determining the appropriate timing of a surgical intervention was carefully
considered. The patient was treated with a preoperational weight loss program for 16 0 days during an educational
hospitalization. At the point when BMI became 39.0 kg/m 2 and HbAlc became 6.8%, a laparoscopic sleeve gastrectomy was
conducted for the patient. The postoperative process was satisfactory where BMI and HbAlc improved to 31.7 kg/m 2 and 6.0 %respectively by postoperative day 80. This study reported a successful case of weight loss and improvement in diabetes which
was achieved by a clinical team which performs medical practices including a bariatric surgery for a patient with juvenileonset and standard medical therapy resistant obesity associated with type 2 diabetes.

KEY WORDS: obesity, type 2 diabetes mellitus, metabolic surgery, laparoscopic sleeve gastrectomy, bariatric surgery

Introduction

The prevalence of severe obesity among adolescents
continues to increase, and individuals with complications fromtype 2 diabetes mellitus (T2DM) also increases in number 1, 2).
Furthermore, cases of juvenile-onset morbid obesity and
T2DM are refractory and resistant to medical therapy. Thesepatients tend to have diversified background factors suchas mental, psychological and social problems 3-5). However,leaving patients without treatments would trigger various
obesity-related complications, which would induce a lowered
quality of life and increased mortality rate 6). Obesity treatment
outcomes from recent studies have found that surgicaltreatments for morbid obesity provide significant effect andefficacy 7- 10). However, this must be applied with deliberateconsiderations of patients’ background factors. This study
reported a successful case of weight loss and improvement
in diabetes experienced with a bariatric surgery for a patient
who the above-mentioned factors applied to.

Study case

The patient: a female at the age of 28 years.
Chief complaint: diabetes mellitus; therapeutic purpose ofobesityAnamnesis: at the age of 10; a surgery of slipped capital		
femoral epiphysis (both sides)
at the age of 18; onset of acute lymphocytic		leukemia (chemotherapy from		
age of 18 to 20, remission after		
then)at the age of 18; adjustment disorderat the age of 19; dysthymia
at the age of 22; emotionally unstable type		
personality disorder, 				
alcohol dependence, lumbago,
		hyperlipidemia and fatty liver
Family history: father: chronic pancreatitis, hypertonia,
		hyperlipidemia and diabetes

Corresponding author: Shingo Iwata M.D., Ph.D.
Department of Surgery Takeda General Hospital
28-1 Ishida Minamimori Hushimi-ku Kyoto 601-1495, Japan
Tel: +81-75-572 - 6331 Fax: +81-75-571- 8877 e-mail: s-iwata@takedahp.or.jp
Co-authors: Hagiwara A, ahagiwar@mail.doshisha.ac.jp ; Kato H, hitokatoyu@yahoo.or.jp ;Nakamae K, nakamae@mub.biglobe.ne.jp ; Fujikura J, j-fuji@sannet.ne.jp ;Inagaki N, inagaki@metab.kuhp.kyoto-u.ac.jp_ 30 _

Glycative Stress Research 2018; 5 (1): 030-035(c) Society for Glycative Stress ResearchGlycative Stress Researchmother: neurodystonia
paternal grandmother: hepatitis C
two maternal uncles: diabetes
maternal grandfather: diabetes (dialysis)maternal grandmother:			
diabetes (leg amputation) and			
cerebral infarction
Life history: smoking history: 40 cigarettes per day for 14
				
years
drinking history; wine: 3,000 mL/day, shochu(Japanese spirit distilled from sweet potatoes,
rice, etc.) 1,500 mL/day
Clinical history: The patient had been obese since she wasan elementary school child. The weight was 58 kg at theage of 10, 78 kg at 11, 90 kg at 12, 108 kg at 13 and 121
kg at 15. Diabetes was diagnosed at the age of 17 by A
hospital and weight loss was attempted but resulted in a
failure. Acute lymphocytic leukemia was diagnosed at theage of 18. At the beginning of chemotherapy, glycemic
control was unsuccessful and insulin therapy was applied.
Treatments were changed from insulin to oral antidiabetic
agent at the age of 20 when acute lymphocytic leukemia
entered remission. Then, oral antidiabetic agent treatment
continued. However, HbAlc elevated from 7% to 9% andshe was hospitalized in B hospital at the age of 22. She
tried to reduce her weight by only 3 kg. At the age of 24 at
112.4 kg of weight, 10.0% of HbAlc and over 2,000 mg/
dL of triglyceride (TG) (occasionally), pain in the backwas mentioned, which was suspected to be pancreatitis.
After transitions of varied antidiabetic agents, GLP-1(glucagon-like peptide-1) receptor agonist, biguanide, SGLT2 (sodium glucose co-transporter-2) inhibitory agent andthiazolidinediones were finally administered for treatment.
However, morbid obesity was not improved with 127.7 kgof weight (body mass index [BMI] = 46.1 kg/m2 ) and 9.4%
of HbAlc. Therefore, it was judged that the internal therapy
reached its limit. The patient was referred to this hospital foran adaptation of surgical treatments.
Clinical data of the first visit: morbid obesity was recognizedwith a height; 165.5 cm, weight; 127.9 kg, BMI; 46.7 kg/m2
and blood pressure; 125/97 mmHg.
Clinical examination outcomes of the first visit: highvalue, 9.8% of HbAlc; leukocytosis; polycythaemia; γ-GTP
increase; total cholesterol (TC) increase; TG increase.

Ethical standard
Before starting this surgery, a written consent was
obtained from the patient. This study was implemented incompliance with the Helsinki Declaration (as revised in 1975,1983). This study was approved by the ethics committee of
this hospital.

Therapy policy
The patient was educationally hospitalized to determine
if she was eligible for an adaptation of a bariatric surgery.
Since the patient moved to this hospital, as drugs forsleeplessness and anxiolytic drugs had been prescribed
as a single use (medicines to be taken as needed) by otherhospitals, this hospital prescribed ramelteon (8 mg/day) andbrotizolam (0.5 mg/day) for sleeplessness, and tramadol (75mg/day) and duloxetine (20 mg/day) for external injuries andchronic lower back pain due to obesity.
The aims of the educational hospitalization were as follows:
1) weight loss and diabetes control2) evaluation of the capability for the patient to endure dietary
restrictions3) guidance for appropriate eating manners
4) observation and assessment of behavioral patterns of having
low caloric diet including a formula meal5) assessment to judge if she would be able to withstand more
severe diet control post-operation
6) loss of weight to reduce the quantity of visceral fat so thatthe lateral division of liver, which was compensatory
hypertrophy due to fatty liver, could be reduced to as little
as possible for the surgery to be conducted safely
Diet started with meals 1,400 kcal/day. Treatment of
hypoglycemic agents had been combination chemotherapy
but a single administration of SGLT-2 inhibitor tofogliflozin
20 mg/day started and was observed to assess the effect todetermine if additional administrations were needed.
Endocrine examinations were conducted, and it was
confirmed that the patient had primary obesity. Furthermore,a psychological test was conducted, referring to the clinicalrecord from the introduction of the original medical
institution, which showed that the patient had social andmental problems. Results of the test were as follows:
Results of an intelligence test:• The patient was skillful in dealing, on an individual level,with information required for daily life but it was difficult
to store knowledge and apply knowledge to solve problems.
Results of a personality test:•		The patient did not have an emotional disturbance at thetime of the test.
• The patient had difficulty having objective recognitions of
the actual world and tended to behave following emotion
or desire rather than reason.
• With low self-esteem, she did not have active interests andrarely initiated an action.
• The patient did not have feelings of adherence to a belief
or principle and it was hard for her to have her own opinion
with self-assertiveness.
• With little sense of a code of conduct, it was difficult tofollow rules.
• The patient was not good at controlling her behavior
reasonably and positively to achieve a goal.
Her concept of self-management:• The patient had intensive fear toward disease complications
associated with obesity and was motivated to undergo selfmanagement. Thus, it was a very good timing to make anintervention.
• The patient did not have complaints about meals. However,
she would be unable to refrain from drinking after leaving
the hospital.
• The patient had friends to go on a diet with, but her family
was not interested in her. She felt that she was not able tohope that her family would support her.
The point of an intervention:• Understanding and incorporation of people around thepatient would be necessary in her struggling with thischallenge.
• It was necessary to keep away from negative attitudes andbuild a corporative relationship.
• To explain to and motivate the patient so that she could_ 31 _

Bariatric Surgery Case of Juvenile-Onset and Therapy-Resistant Obesity with Type 2 Diabetes

Body weight (kg)For the surgical indication, a clinical team conducted
meetings convened to discuss issues, including surgeons,specialists in diabetes endocrinology, psychiatrists, clinicalpsychologists, national registered dietitians, physicaltherapists, pharmacists, nurses and social workers. It was
found from the psychological test results that the patient had
observed severe clinical conditions of her family members
and relatives, such as disease complication due to obesity
and much more serious problems such as leg amputations
and dialysis induced by severe diabetes. Thus, she seemed
to have strong desire to have the obesity and diabetes cured.
The clinical team concluded unanimously that the patient
was ready for a surgery with sufficient motive to solve theproblems of obesity and diabetes. It was determined that thepatient had a good timing for the intervention of a bariatricsurgery.

Clinical course from the educational
hospitalizations to the surgery

Fig. 1 showed the changes in body weight and HbAlc at
six hospitalizations. The first admission started with a diet of
1,400 kcal/day and physical exercise therapy and achieved 10
kg weight loss from 127 kg to 117 kg after about one month.
Fasting blood glucose level was lowered from 228 mg/dL
to 137 mg/dL, which showed that a single administration of
SGLT-2 inhibitor was effective. Therefore, it was decided
that the single administration was would continue without
adding other agents. The patient left the hospital and stayedhome for one week. Then the second admission started witha body weight of 117 kg, which was maintained without
weight gain from the time of leaving the hospital. Therefore,
the second admission also started with a diet of 1,400 kcal.
HbAlc decreased smoothly to 8.2 %. Body weight was
reduced from 117 kg to 110 kg and fasting blood glucose
level was improved from 213 mg/dL to 104 mg/dL during
the second admission. In the third admission, the patient’s
diet was 1,200 kcal/day, in which formula meals were added.
However, the conditions during the third admission was thatbody weight was reduced from 108 kg to 105 kg, fasting
glucose level was reduced from 151 mg/dL to 98 mg/dL, andHbAlc was between 7.2 % and 6.7%. In the fourth admission,
the amount of formula meals was increased, and the total
calorie count of the meals was limited to 600 kcal per day.
However, body weight (from 107 kg to 108 kg) did not showa change. It was considered that a surgery was planned in
the coming fifth admission on the grounds that the physicalconditions of BMI: 40 kg/m2 or lower and HbAlc (6.7%):

140

14

120

12

100

10

80

8

60

6

40

4

2

20
0

50

100

150

Days
Fig. 1. Clinical course: Changes in body weight and HbA1c.
LSG: Laparoscopic sleeve gastrectomy.

_ 32 _

200

250

HbA1c (%)

tackle the challenge with self-efficacy.
• To explain concretely and specifically with sufficient andconcise words.
• To begin with something that the patient thought she coulddo.
• To encourage the patient to take the initiative and set a
goal. To praise her in an achievement and to help her to
identify the factors of a failure, which could enhance her
self-efficacy.
• To help the patient, asking her about feelings and ideasthat she had, to put into words what she felt or thought in
her mind. Employing this approach, the patient was able toface her own feelings and ideas.

Glycative Stress Research

7% or lower indicated a safe surgery and also the effectsof the diet and physical exercise therapy reached its limit.
However, the planned surgery was canceled in the fifth
admission, because the body weight of the patient was 116
kg, which had increased by 8 kg. The reason was a massive
calorie intake of food, which was referred to as “the lastsupper.” Then, the team of obesity and metabolism experts
conducted a meeting again to determine the three conditions
to perform a surgery as follows:
1) To confirm the intent of the patient2) To reduce the body weight during the fifth admission (thetarget goal was BMI: 40 kg/m 2 or lower)
3) Maximum weight gain to be permitted at the next admission
was 2 kg or lower
The patient was informed that a surgery would be
performed if these conditions were fulfilled, and then she
consented to these conditions. Consequently, these requiredconditions were obtained with a body weight of 107 kg
upon leaving the fifth admission and 108 kg at the sixth
hospitalization. Therefore, a laparoscopic sleeve gastrectomy(LSG) was conducted during the sixth admission. The wholeprocess of preoperational weight loss was as follows: fiveeducational hospitalizations with periods between two andfour weeks which employed diet and exercise therapy andachieved 20 kg in weight loss from 127 kg ( BMI = 46 kg/
m 2 ) at the first visit to 107 kg ( BMI = 39 kg/m 2 ).
In terms of hypoglycemic agent, a SGLT-2 inhibitor wasprescribed and HbAlc was improved from 9.8% to 6.8%.
Visceral fat area was estimated at the first hospitalization
date and immediately before the surgery, by using a visceralfat analyzer HDS- 2000 (Dualscan, Omron Healthcare Co.,
Ltd., Muko, Kyoto, Japan) 11). At the first admission, thevisceral fat area was 225 cm 2 , girth of abdomen was 140
cm, which improved to 124 cm 2 and 125 cm respectively
prior to the surgery. In Table 1, the data of blood examination
immediate before the surgery showed a lipid abnormality.
The surgery was conducted on the 160 th day from the firsteducational hospitalization.
Laparoscopic sleeve gastrectomy (LSG) 12): Under ageneral anesthesia, the procedure involved a longitudinal
resection of the omentum majus starting from the antrum
at the point 4 cm from the pylorus in greater curvature ofstomach and finishing at the His angle. After resection of theomentum, the stomach was resected on the side of greater
curvature by a surgical stapling device with the guidance

Table 1. Laboratory data on first visit, preoperative day 1, and postoperative day 80.

WBC

/μL

Hb

g/dL

Hct

%

Plt

x104 /μL

TP

g/dL

Alb

g/dL

T-Bil

mg/dL

AST

IU/mL

ALT

IU/mL

ALP

IU/mL

LDH

IU/mL

γ-GTP

IU/mL

BUN

mg/dL

CRE

mg/dL

TC

mg/dL

HDL-C

mg/dL

LDL-C

mg/dL

TG

mg/dL

HbA1c [NGSP]
CRP

%
mg/dL

First visit

Preop 1

Postop 80

10,900

9,600

6,600

16.5

15.7

14.8

50.6

47.2

45.7

20.6

18.8

17.3

6.5

6.5

6.4

4.3

4.0

4.0

0.5

1.1

0.3

21

16

18

37

17

16

182

197

210

188

183

165

65

64

37

14

10

17

0.47

0.50

0.66

220

265

186

74

49

66

104

160

105

521

431

120

9.8

6.8

6.0

0.05

0.42

0.38

Preop 1, Preoperative day 1; Postop 80, postoperative day 80; WBC, while blood cell; Hb, hemoglobin; Hct, hematocrit; Plt, platelet; TP,
total protein; Alb, albumin; T-Bil, total bilirubin; AST, aspartate transaminase; ALT, alanine transaminase; ALP, alkaline phosphatase;
LDH, lactate dehydrogenase, γ-GTP, gamma glutamyl transpeptidase; BUN, blood urea nitrogen; CRE, creatinine; TC, total cholesterol;
HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TG, triglyceride; NGSP, natinal
glycohemoglobin standardization program; CRP, C-reactive protein.

_ 33 _

Bariatric Surgery Case of Juvenile-Onset and Therapy-Resistant Obesity with Type 2 Diabetes
of an endoscope. Thus, after surgically removing a stomach
section, a small diameter gastric tube, which is a reduced
stomach portion, was produced. It was inspected by theendoscope that there was no bleeding, nor contraction within
the stomach, after reinforcing the staple-line.
The data from postoperative day 80 showed that the bodyweight was 87 kg (BMI = 31.7 kg/m2 ), the weight loss fromthe first visit was 40 kg, and HbAlc was improved from 9.8%
to 6.0 %. The visceral fat area was remarkably decreased from225 cm2 to 77 cm2 . The data from the blood test showed thelipid abnormality was improved in Table 1.

Discussion
T2DM associated with juvenile-onset and morbid
obesity has been an increasing social problem in Japan 1).
In comparison to diabetes characteristics of Europeans andAmericans, Japanese diabetes tends to occur at a relatively
low BMI level and juvenile-onset diabetes accounts for
20% of all the diabetes and is said to have dissatisfactory
convalescence. Among patients who became T2DM by 35
years old, 60% of the patients resulted in dialysis or ablepsia
by 60 years old 6). T2DM morbid obesity patients are provided
therapies of dieting, physical exercise and medication.
However, no internal therapies show long-term therapeutic
effects, and especially young-onset diabetes is refractory.
The case in this study also showed that the patient had beentreated in a specialized hospital for ten years and the weightloss treatments were not successful. The reason in this case
was assumed that the patient held personality-related, mental
and social problems other than nutritional and metabolic
factors. Serious morbid obesity mostly involves personality
characteristics which results in difficulties for treatment.
It has been proven that bariatric surgeries showed along-term effect on weight loss in comparison with medical
or internal therapies 9). It has been reported that due todevelopment in a laparoscopic surgery, bariatric surgeries
have rapidly increased in number and data on bariatricsurgery outcomes have been accumulated, which recognizedthat mortality rate related to morbid obesity is improved due
to bariatric surgeries 13, 14), and obesity-induced metabolic
diseases are improved or cured 8, 9). In this case for thesurgical therapy, mental problem must also be considered,and a surgical indication required prudent responses.
Guidelines in Japan stipulate that patients with obesity
are likely to have mental and psychological traits, and it isdesirable that patients are interviewed by psychiatrists or
clinical psychologists for assessment to obtain advice forcautionary points at pre-operation and during follow-up 15).
Following this guidance, the patient underwent psychologicalexaminations, which revealed the personalities of the patients.
It was found that due to the psychological tests that the patient
was in the good timing for an intervention. Furthermore,a clinical team was established, consisting of surgeons,
psychiatrists, internists, clinical psychologists, nurses, national
registered dietitians, physical therapists and social workers,
and the treatments were performed with mutual cooperationand combination work.
The patients with personal traits similar to the patientin this study case require a clinical team to support them, as
their self-esteem is low, they face diversified obstructions tolive a social life, and their quality of life is low physically,
mentally and socially. Not only support for body weight

loss, but also for the improvement of the quality of life are
crucial challenges 16, 17). For patients to build up a successful
experience of their own, an empowerment approach must be
employed by clinical professionals 18). This type of support
system cannot be achieved by a single medical profession.
Once diversified occupations join forces with each other,co-operation is enabled. This patient has only a short-term
postoperative observation period of 80 days, so follow-up
is essential in future. The team work will be necessary toreassure the patient not to rebound in the future.
The preoperative weight loss was achieved relatively
smoothly due to the good timing of the intervention. The
clinical team was able to overcome the weight gain in thefifth admission. Leaving the hospital after fourth admission,
the weight of the patient had increased again. However,during the fifth admission, the weight was decreased by thesame amount as the fourth, due to the support of the team. If
the patient had been left without appropriate clinical support,
she would have rebounded in body weight and would havebeen unable to undergo surgery. It was recognized that thesurgery was performed at the correct timing, as medical
therapy had reached its limit in weight loss and the patient
was led to be in a safer condition for the surgery.
Patients with morbid obesity have higher risks during
surgery and under anesthesia in general 19, 20). Excessive
offal fat and hepatomegaly due to fatty liver diseases makethe working space narrow intraperitoneal so that surgicaloperations have difficulties, to a great extent. It was shownthat preoperative weight loss by intaking low calorie meals
can significantly reduce the quantity of offal fat and thevolume of the liver, which is highly recommended in termsof the decrease in disease complication related to surgicaloperations 21). In fact, the visceral fat area of this patient
was reduced, and the surgery was performed safety andsuccessfully. There was no disease complication related
to the surgery post-operation, and the weight loss and theimprovement in diabetes were successfully achieved.
It is reported in Japan that medical care expenditure isincreased for patients with T2DM with obesity 22). However,myriad cases have been shown of insufficient controlof blood glucose, while therapeutic agents prescribed tocontrol blood glucose, blood pressure and lipids increase
the complications of obesity, and more careful and attentive
treatments are necessary. Not only in Japan, but also in the
United States of America, medical costs have been increasing
year by year. It has been revealed that diabetes requires thehighest medical expense of all disease states 23). Obese andmetabolic surgeries have drastic effects not only on weightloss but also on diabetes. It has been recognized that bariatricsurgeries can reduce or put an end to medical therapy, whichis greatly beneficial on the medical economy 24). Furthermore,bariatric surgeries can reduce glycative stress and lead to theprevention of glycative-stress-related disease complications.
It is hoped that surgeries for weight loss and metabolism willdevelop and contribute to the society as an effective method
for fighting obesity and diabetes.

Conclusion
The successful clinical case of LSG was experienced
for a patient with juvenile-onset and standard medical
therapy resistant obesity associated with T2DM. The clinicalteam supported the patient with mental and psychological_ 34 _Glycative Stress Research

problems to have educational hospitalizations with successful
preoperative weight loss. LSG was performed for the patient
and weight loss and diabetes were improved.

Conflict of interest
There are no items related to conflict of interest for thisstudy to conduct.

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