Preliminary Case Report on the Change in Metabolic Profile in Non-Obese Type 2 Diabetic Patients treatedwith Surgery in the Philippines

Dineros, Hildegardes C.

Background: The metabolic effects of bariatric surgery, particularly the remarkable resolution of TypeII DM are well established. Several mechanisms of action have been proposed in addition to weight loss
as the major factor causing such improvement in co-morbidities. The aims of this presentation are asfollows: 1. To describe a novel procedure, the Laparoscopic Sleeve Gastrectomy with Loop Duodeno-Jejunal
Bypass; and 2. To present the observed changes in metabolic panel in 3 patients before and after MetabolicSurgery.
Methods:From January 1, 2008 to December 31, 2010, three (62 and 56 y/o females, and a 43 y/o male)non-obese patients with medically uncontrolled Type 2 Diabetes Mellitus underwent Laparoscopic Sleeve
Gastrectomy with Loop Duodeno-Jejunal Bypass. Preoperative profile was taken and compared to 1,3, 6,
12 and 24 months.
Results: All 3 patients had 3 months follow-up data, 2 had 6 and 12 months follow-up data and 1 had 2years follow-up data. Decrease in BMI ranged from 1-3 kg/m2.

Improvement of FBS, HbA1c was noted as

immediate as 1 month postoperatively with discontinued Oral Hypoglycemic medication and Insulin as earlyas 3 months after surgery. No surgical morbidities were noted.
Conclusion: Laparoscopic Sleeve Gastrectomy with Loop Duodeno-Jejunal Bypass can be performed safely.
There are multiple mechanisms for its euglycemic effect, a subject for further investigation.

Affiliations:
Department ofSurgery, St. Luke’s Medical Center, Philippines

Bariatric & Metabolic Institute, Cardinal Santos Medical Center, Philippines

Metabolic outcomes of bariatric surgery: a result from Thai Subjects

Chula Minimally Invasive Surgery Center, Department of Surgery, Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand 10330
Udomsawaengsup S, Tansawet A, Timratana P,

Prathanvanich P, Pungpapong S, Tharavej C, Navicharern P

Background: Obesity and its co-morbidities become to be one of the most important health care problems.
Weight loss surgery has been proved as the most effective and sustainable method to obtain long term
weight control and to achieve improvement of metabolic disorders. There are limited results contributing
from Asian subjects. We reviewed our metabolic outcomes of surgical treatment for morbidly obese patientsin our institute.
Methods: Data from all patients who underwent bariatric surgery in Chulalongkorn University werecollected and metabolic outcomes were reviewed.
Results:

From Jan 2003 to December 2010.

Fifty-five consecutive Thai patients underwent bariatricsurgery by the Chula Minimally Invasive Surgery Center. The mean age was 35.2 years (18-57 years). Twenty
four (56.4%) were men. The pre-op BMI was 49.2 kg/m.2 Roux en Y Gastric bypass was the most common procedure(78%). In RYGB group showed mean EWL of 64.2% at 2 years. 20 of 55 (36.3%) were type II diabetic, allof them were getting improvement post operatively; of which, 81.8% were completely resolved and 18.2%
were able to decrease dosage of hypoglycemic drugs.

28 of 55 (50.9%) were hypertensive, 46.7% of themwere able to discontinue antihypertensive drugs and 46.7% were decreasing dosage. 19 of 55 (34.5%) weredyslipidemia; 60% were resolved and 40% were improved.
Conclusion: Metabolic results in Thai patients undergoing bariatric surgery are excellent. This initial
data from Thai subject reflects a comparable result worldwide.

Comparison Between the Effects of Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric
Bypass on Type 2 Diabetes Mellitus in Morbidity Obese Japanese Patients: A Retrospective 1 Year Study

1

The Department of Weight Loss Surgery, Yotsuya Medical Cube, Tokyo, Japan

Hideharu Shimizu1,Yosuke Seki1,Eri Kikkawa1,Kazuko Sonoda1,Tetsuya Nakazato1,Kazunori Kasama1<Background>Laparoscopic Roux-en-Y gastric bypass (LRYGB) provides sustained weight loss and leads towell-documented remission of Type 2 diabetes (T2DM), whereas data on the effectiveness of laparoscopic
sleeve gastrectomy (LSG) on T2DM are scarce<Methods>We conducted a retrospective study on the therapeutic
effect on type 2 diabetes and biochemical characteristics in 16 morbidly obese T2DM subjects undergoing
LSG and 24 subjects undergoing LRYGB before and at 1, 3, 6, 12 months after surgery, matched for age,gender, BMI, fasting plasma glucose, HbA1c, insulin, C-peptide, HOMA-IR, DM duration<Results>The
preoperative median BMI was 40.8 kg/m2 in the LSG group and 44.9 kg/m2 in the LRYGB group and as for
T2DM, most subjects were not severe type from their history and biochemical markers. The percentage ofexcess weight loss at the 1, 3, 6, 12-month follow up points after LSG and LRYGB were 28.8 and 27.8,
46.2 and 47.0, 64.2 and 63.9, 74.2 and 71.8%, respectively. The remission rate of T2DM at the same followuppointsafterLSG

andLRYGB

were38and35,75and73,87and93,93

and100%,respectively.<Conclusion>For not severe T2DM in Japanese morbidly obese Japanese patients, thetherapeutic effect of LSG and LRYGB on T2DM was comparable at 1-year interval.

Laparoscopic Duodenojejunal bypass with Sleeve gastrectomy- A novel procedure for resolution of Metabolic
Syndrome in patients with BMI <32.5:

1

Gem Hospital and Research Centre,

Praveen Raj1,C Palanivelu1

Background:Type II DM resolution in morbidly obese patients following Metabolic Surgery suggests thesemight benefit even non-morbidly obese patients with Metabolic Syndrome. Available literature favours
Combined Restrictive/Malabsorptive procedures over the others in control of Diabetes and otherco-morbidities. Laparoscopic Duodenojejunal bypass with Sleeve gastrectomy is one such procedure
performed in our series.Methods:Patients with < 32.5BMI, confirmed to be Type IIDM with HbA1C >7.5 wereincluded in the study. Patients with Sliding Hiatus Hernia and C-peptide levels < 1 were excluded.
Laparoscopic Duodenojejunal bypass was done in a retro colic fashion, anastomosis being done end-end,
single layer suturing with a 60 F Sleeve.Results:A total of 14 patients (8 women, 6men) included in thestudy were prospectively evaluated. The mean age was 36.5yrs.The mean pre-operative BMI, (Fasting BloodGlucose) FBG and HbA1C was 29.9,196.4mg/dl and 8.2%.The postoperative BMI,FBG and HbA1C at the end of6mts and 1 year was 25.4,110.2,6.3% and 24.2,106.4,6.1% respectively. 12 out of 14 patients had complete
remission and 2 had reduced medication use.4 out of six patients who had Hypertension had completeremission, 2 had no improvement. Conclusion:Laparoscopic Duodenojejunal bypass with Sleeve, which
combines the principles of Sleeve Gastrectomy and Foregut hypothesis, is an effective procedure forresolution of Diabetes and other co-morbidities even in lower BMI population. The stomach remnant isamenable to endoscopic surveillance for Carcinoma Stomach. Also with the possibility of altering thesize of the Sleeve, the procedure can be made less restrictive which is best suited for a country like
India with a low calorie-higher quantity food intake pattern, hence preserving the quality of eating.

SLEEVEGASTRECTOMY : METABOLIC AND BARIATRIC SURGERY

M.S., DLS(India), DLS(France), FAIS , Fellow

A

BLESSING FOR THE ASIANS:Bariatric surgery ,Cleveland Clinic ,USA

Institution : Ruby Hall Clinic , Pune , India .
Jayashree Todkar:Dr L H Hiranandani Hospital , Mumbai, India .

1

OBESITY---GLOBALEPIDEMIC

 Pro-atherogenic disease(WHO)with

DysmetabolicstateSouth Asians around the globe have highest rate of Coronary Arterial Disease (CAD ) .
 There would be around 62 million pts of CAD

in India by 2015 and out of these 23 million would

be pts lesser than 40 yrs of age.
DM BURDEN IN INDIA Approx. 43 million adults are Diabetics
 Estimated to increase to 57.2 million by 2025.
Asian Consensus•

Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for
Asian Indians and Recommendations for Physical Activity, Medical and Surgical Management:Normal BMI: 18.0-22.9 kg/m2,
Overweight: 23.0-24.9 kg/m2,
Obesity:> 25 kg/m2

JAPI

2009.
More CVD ,DMrisk at lower BMI

DIS-SENSITIVITY ,INDIAN
AEXPERIENCE

in Asian population are due to : 1- BODY COMPOSITION, 2- INSULIN

3- CENTRAL DISTRIBUTION OF FAT.
OF SLEEVEGASTRECTOMY :. Effectiveness of laparoscopic sleeve gastrectomy on glycemic control in obese Indians with type2 diabetes mellitus
B . Long-term effects of laparoscopic sleeve gastrectomy in morbidly obese subjects with type 2 diabetes
mellitus
C . Impact of LSG on CVD risk reduction

using Framingham score

Improvement in Type 2 Diabetes Mellitus following Bariatric Surgery in morbidly obese individuals

1Department of General Surgery, Singapore General Hospital 2Department of Endocrinology, Singapore

General Hospital
Shanker Pasupathy1,Chin Hong Lim1,Daniel Wai2,Kwang Wei Tham2

BACKGROUND: Weight loss has been shown to improve the control of type 2 diabetes mellitus (T2DM). AIMSOF STUDY: To evaluate the impact of bariatric surgery on T2DM in morbidly obese individuals. METHODS:
From August 2008 to November 2010, 47 consecutive patients underwent bariatric surgery at the Singapore
General Hospital. All patients documented to have T2DM prior to surgery were included in thestudy.RESULTS: There were 16 patients suffering from T2DM (9 males). The median age was 43 years (range32 - 54). 8 patients underwent laparoscopic sleeve gastrectomy (LSG) and 8 underwent laparoscopic gastricbypass (LGB). Median length of stay was 4 days (3-14). The median pre-operative weight was 116kg (85-171) and body mass index (BMI) 40 kg/m2(33 - 70). Median follow-up was 5 months (1 - 26). Patients who
underwent LSG had a median pre-operative HbA1c of 7.2% (6.4-8.2). All these patients were taking oral
hypoglycaemic agents (OHAs). Median post-operative HbA1c levels were 5.8% (5.5-6.1), and all OHAs werediscontinued. Patients who underwent LGB had a median pre-operative HbA1c of 8.2% (6.6-9.3). 5 patientswere on subcutaneous insulin injections, in addition to oral hypoglycaemic agents (OHAs). Medianpost-operative HbA1c levels were 6.1% (5.2-8.0), and although insulin was discontinued in all, 2 patientswere still taking OHAs. CONCLUSION: Bariatric surgery provided rapid and effective control of T2DM,
allowing all patients to reduce or eliminate diabetic medication completely. Bariatric surgery may beconsidered as an adjuvant therapy for T2DM in morbidly obese individuals.

DUODENOJEJUNAL BYPASS IN DIABETIC GASTRIC CNACER PATIENTS

Department of Surgery
Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
Daehyun Yang, Jiwon Kim, Kyungsuk Jung(Objective) Metabolic surgery

in non-obese diabetics has been tried by various

methods. Effect of duodenojejunal bypass on diabetes could be studied by themodification of reconstruction after curative gastrectomy for diabetic gastric cancer
patients.
(Method)

FromJune

2007

toDecember

2009

weperformed

ourmodified

RY

gastrojejunostomy procedure of duodenojejunal bypass with bypassed proximal jejunumover 100cm after curative distal gastrectomy for 18 diabetic gastric cancer patients.
The bypassed proximal jejunum were 100-190cm ( 134.3cm in average ) as the sum ofReux and Y limbs. The durations of diabetes were 6.4 years in average, and diabetes
was managed by oral hypoglycemic agent in all of the patients.
(Result) Diabetes had been remitted in 7 patients among 18 patients ( 38.9% ) at the
1 year or more follow up, with HbA1c level of 7.0% or less without medication. The
serum ferritin and VB12 levels were within normal limt in most of patients.
(Conclusion)

Bypassofduodenum

andlengthened

proximaljejunumwithdistalgastrectomy is acceptable in nutrition. Some portion of diabetic gastric cancer
patients could be in remission of diabetes with bypass of duodenum and long proximal
small bowel in gastric cancer surgery. Randomized prospective clinical trial of
metabolic surgery for diabetic gastric cancer patients is necessary to evaluate themetabolic effect of duodenojejunal bypass on non-obese diabetics.