Surgical treatment 1O-y follow-up13 Wafter Melvin Stuart
of obesity
J Pories, Kenneth G MacDonald S Swanson, Hisham A Barakat, D Long, Kevin F 0 ‘Brien, and
ABSTRACT
Since
Greenville
gastric
1980
bypass
procedure
with an acceptable
morbidity
obese patients of 1 .2%. The
weight
loss
the follow-up
period
of 10 y. The
in the
series 0GB
62 (13%)
dividuals,
141
who
reverted
with inadequate patients
who
were
were
oftheir
older
can
control
impaired. and
morbidly
only
patients. NIDDM
22 (5%)
metabolism.
diabetes
rate over
non-insulin-
was oflonger
163
in-
remained Those duration
were less likely to revert to normal values. The gastric bypass operation is an effective approach for the treatment of morbid obesity. Along with its control ofweight, the operation also controls the hyperglycemia, hyperinsulinemia, and insulin resistance of the majority frank NIDDM.
KEY
of patients
Am
WORDS
diabetes gastric
with
J C/in Nuir
Diabetes
mellitus, bypass
either
glucose impairment l992;55:582S-5S.
mellitus,
hypertension,
or
obesity,
bariatric
surgery,
Introduction Obesity
of adult
is one
ofour
Americans
most
serious
are obese
health
and,
problems.
of these,
Over
ofthis
relationship
recognized insulin
between
obesity
for centuries, resistance
is not
and
the
and
clear
eventual
diabetes,
but failure
glucose
obesity improves,
is treated along
and functional Since 1980 bypass ((3GB)
operation, 582S
concentrations
rise
successfully with
the
with amelioration
out
surgery,
the
obesity is The cause to be due
of the
of control.
3 and 7 body weight
pancreas
diabetes
usually arthritis,
effectiveness.
in Figure
3, reduces
the gastric Am
J C/in
reservoir
Nuir
creation
of a small
reservoir,
delays
emptying
with
the
gastrojejunostomy, bypasses the endocrine mechanisms of the foregut, and produces dumping when high-carbohydrate fluids
flow
directly
into
the jejunum.
The 0GB produces excellent weight loss. Based on intensive follow-up in which data on all but 17 (4%) of the 479 patients were available, Table I and Figure 4 demonstrate that maximum weight loss is achieved at ‘-24 mo and is well maintained with only a 10% weight gain even after 10 y. Most bariatric surgery can be performed with a mortality of 1%, depending
Those high
on
bariatric incidence
the
centers
risk
that
of serious
level
operate
of the
patient
on heavier
complications
such
population.
patients as cardiac
with
a
failure,
syndrome, severe diabetes, crippling arthritis, and malnutrition tend to have higher complication rates. Our perioperative morbidity and mortality are shown in Table 2. The gastric bypass is remarkably effective in the control of NIDDM. The effectiveness of that control is demonstrated in Table 3 by the correction of the abnormal concentrations of fasting glucose, fasting insulin, glycosylated hemoglobin, and the intravenous tolerance test. None ofthe patients in this small cohort require any further therapy for NIDDM. The group of 479 patients included 10 1 (2 1%) with NIDDM and another 62 (13%) who were glucose impaired (IGT). Of these 163 individuals, 14 1 reverted to normal and only 22 (5%; 21 with
NIDDM
and
1 with
these
we have performed the identical Greenville gastric procedure on 479 morbidly obese patients. The
diagrammed
the
to
morbid
of hypertension,
with
to
Figures 1 of patients. to rise with to keep up, and, thus,
When
Dohm,
to 30 mL, tightens the gastric outlet to 0.8 cm, bypasses the antrum and duodenum, and empties the chyme directly into the proximaljejunum. Functionally, the operation limits intake
trol of their carbohydrate globin > 8 mg% or fasting
a relationship
appears
meet the ever higher demand for insulin production. and 2 demonstrate this progression in five groups The data suggest that insulin production continues increasing insulin resistance until the fi cells, unable fail to reach effective insulin production on demand blood
45%
between
million are morbidly obese, exceeding their ideal by 45 kg. The most grave consequence of severe non-insulin-dependent diabetes mellitus (NIDDM).
G Lynis
Pickwickian
non-insulin-dependent
morbid
Madhur K Sinha, Nancy Leggelt-Frazier,
small The and
Of these
carbohydrate
or whose
479
in most (21%) with
glucose
to normal
control
the identical
on
and a mortality well maintained
was
dependent diabetes mellitus (NIDDM) group of 479 patients included 101 another
Jr, Elizabeth J Morgan, Prabhaker G Khazanie, Jose F Caro
performed
we have
(GGB)
and its effect on diabetes:
1992;55:582S-5S.
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/582S/4715355 by guest on 26 February 2018
7 were
22, 1 1 were taking
taking
oral
IGT)
remain
metabolism blood sugar
medication:
with
inadequate
con-
[ie, glycosylated hemo(FBS) > 125 dL/L1. Of
4 were taking
insulin
and
agents.
I From the Departments ofSurgery, Medicine, Biochemistry, Clinical Pathology, and Allied Health, East Carolina University, Greenville, NC. 2 Supported by Pfizer Pharmaceuticals/Roerig Division: “A Compar-
ison ofAmpicillin/Sulbactum vs Cefazolin for the Prevention of Infection in Morbidly Obese Following Gastrointestinal Bypass and Vertical Banded Gastroplasty,” and National Institutes ofHealth, lPOl DK36296 OlAl. 3 Address reprint requests to WI Pories, Eastern Carolina University School of Medicine, Department of Surgery, Greenville, NC 27858. Printed
in USA.
© 1992 American
Society
for Clinical
Nutrition
SURGERY ORAL
GLUCOSE
TOLERANCE
OF
OBESITY
AND
583S
DIABETES
TEST
1500
z (/,
I
C C
I 200
z 900 800
I
300 SNi
I
1W
M0t1r “#{176}r’G2!l
I
I
MI7
sl
1
FIG 1. The oral glucose tolerance test with the progression Insulin production continues to rise with increasing insulin until the islets fail due to exhaustion.
of obesity. resistance
Failure to achieve control ofthe diabetes with NIDDM was due to several causes:
in the 22/163 patients 1) failure to control
weight
such
a
because
staple
oftechnical 2) failure
line,
complications
as dehiscence
to control weight because the pouch, 3) advanced
ofthe
snacking and outeating ofthe diabetes, and 5) severity with
inadequate
had
weight
8 underwent
endoscopy,
which
that 3 had dehisced their staple lines. Patients with good glucose control were ±
1 .9 vs 49.6
± 2.8
of
patient’s 4) duration
ofthe diabetes. Ofthese 22 patients 17 had weight gain. Of these 17 who
control,
gain,
age,
FIG 3. The Greenville gastric bypass consists ofa 30-mL gastric pouch, an 0.8-cm gastrojejunostomy, and a 40-cm Roux-en-Y bypass loop.
y) and
their
diabetes
demonstrated
--8 y younger was of far
hemoglobin,
other which
and
glucose
consistently. fall
i.
not as morbidly obese. in insulin concentrations, concentrations
do
of HBA1C
the same sons
(41.8 shorter
group
for this
abetic
(Fig
7) and
of patients
show
unexpected
indices
The
duration (1.75 ± 0.69 vs 8.79 ± 2.8 y). The concentration of preoperative fasting glucose also determines the degree of postoperative control. Figure 5 compares the postoperative fasting blood glucose concentrations in NIDDM patients with preoperative FBS readings of< 120 mg% and > 120 mg%. The patients with the higher preoperative glucose values experienced greater drops in FBS than their more normal counterparts but leveled out at concentrations that were still abnormal. This response parallels the pattern seen in weight loss, ie, the heaviest patients lose the most weight, but when they level out they are still heavier than those who were The improvements
trations
is not
gastric
fasting
blood
a much
difference
sugar
wider
in the
(Fig
scatter.
behavior
bypass
is not
the
only
testinal bypasses, gastric and wiring ofteeth have
two
bariatric
procedure
that for rang-
and
the vertical banded or a Silastic band). resection
bandings, gastric been promoted,
procedures
morbidity
combined
banding
procedures
yet won
wide
di-
Since the first operation a number ofprocedures
ing from ileocolic bypass, ileojejunal bypass, various plasties, gastric bypasses, gastric resections combined
ceptable
rea-
of these
clear.
ameliorates or reverses diabetes. morbid obesity was done in 1954,
Of these,
8) on
The
have
with may
proven
mortality
gastroplasty Two other an also
wraps, adopted,
gastrowith in-
gastric balloons, and discarded.
to be effective
rates:
the
gastric
with bypass
acand
(either with a Marlex mesh collar approaches, the Scopinaro gastric intestinal
bypass
be useful
approaches
TO
YEARS
and
the but
gastric have
not
acceptance.
glycosylated not
parallel
each
WEIGHT
LOSS
10
POSTOP
In contrast
predictably
to the insulin concentrations, gastric bypass (Fig 6), the concen-
after
400
0.
300 U)
z
C.,
200
z U)
100
0
ITH NORMAl. LEAN
FIG 2. Changes
in fasting
6
1224364860728496108120 MONTHS
NORMAL
IMPAIRED
OBESE
OBESE
insulin
3
NIDOM
NIDOM
OBESE
OBESE
Fes-140
with the progression
of obesity.
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/582S/4715355 by guest on 26 February 2018
POSTOP
FIG 4. Weight loss of the clinically severely obese patients who have undergone the GOB over the last 10 y. The maximum loss usually occurs at about 24 mo and the weight is well maintained over the subsequent 8 y.
PORIES
584S TABLE Weight
obesity
weight
Mean
excess
weight
IOSt
kg
=
=
l2mo(n=416) 24 mo (n = 36 mo (n = 48 mo(n = 60 mo (n = 72 mo (n = 84 mo (n = 96mo(n= 108 mo (n = l2Omo(n=
SValues
322) 247)
95 (56-200) 84(47-180) 82 (48-166) 88 (53-184)
221)
89(52-194)
62(-22-l12)
214)
90
(48-194)
62 (-6-1
167)
91
(55-181)
59
144)
92 (51-171)
59 (-10-109)
151 (94-273)
105)
90(59-156)
57(11-93)
149(105-259)
58)
92
57 (7-95)
148 (104-276)
18)
90(63-145)
54(16-105)
147(97-197)
in parenthess
Virtually
154 (104-282)
71(13-124) 73 (9-1 16) 65 (-8-108)
136(85-268)
144(87-279)
133 (88-248)
operations,
effect
metabolism as well. Detailed in the treatment of NIDDM
(86-263)
145
complications
after
the 0GB
Complication
weight
loss,
data
regarding
im-
is, however,
operation
with
Incidence %
Deaths Perioperative (n = 6) Sepsis(n = 5) Pulmonary embolus (n = 1) Late deaths (over 10 y) (n = 16) Sepsis(n = 1) Myocardial
Fastingbloodglucose(mg%) Fasting insulin (pmol/L) Glycosylated hemoglobin Maximum insulin release
Glucose
disappearance
1.3
sparse. Gleysteen diabetic patients the amelioration
mechanism
1, 1980-April
±
± ± ±
8.0 6.0 0.6 90.0 0.07
reported
the
improvement
of nine
of the antrum
and
duodenum
may
also
be a major
factor. The limitation in the length of this abstract prevents the inclusion of the extensive basic science studies of insulin action in our morbidly obese patients conducted by Caro and his associates (4-6) at East Carolina University. The interested reader is referred to the bibliography for key references to this research. In summary, the gastric bypass operation is an effective apfor the treatment
of weight,
ofmorbid
the operation and
also
insulin
Post-op (p,’s.
20
obesity.
controls
resistance
GGB
NIDDM
Along
the
with
Patient
its control
hyperglycemia,
of the majority
hy-
of patients
Follow-up
bs>12O,,-24)
::.,
\\ \
Avg
b-’
fl2O
fbs>120
l\\\
=
E
1)
15’
w
(n = 17) Minor wound infection (n = 48) Seroma or liquefied fat (n = 48) Dehiscence(n=5) Technical complications Subphrenic abscess (n = 12) Splenic tear (n = 13) Other postoperative complications Pneumonia (n = 9) Arrythmias (n = 7) Required perioperative reoperation (n February
0.65
et al (1)
perinsulinemia,
Wound
S
±
±
after gastric bypass of hyperinsulinism
1) (n = 1)
pernicious (n complications Severe wound infection
(%/min)
±
117.0± 84.0 6.6 372.0 0.88
and Sirinek et al (2) reported and diabetes in another group of 12 morbidly obese. The best comparison between two bariatric operations was reported by Sugerman’s group (3) who studied 16 morbidly obese patients, randomized either to a gastric bypass (n = 9) or vertical banded gastroplasty (n = 7). His data demonstrate that the gastric bypass was more effective in producing weight loss and in the control of hyperinsulinemia and hyperglycemia than the vertical banded gastroplasty. We are currently conducting further studies to determine whether the difference in diabetic control between the two operations is due solely to weight loss or, as we suspect, the bypass ofthe endocrine
proach 3.4
infarction
Anemia,
rate (%) (pmol/L)
15.0 42.0 1. 1 66.0 0.08
±
I ± SD.
Cancer Liver(n= I) Larynx (n = 1) Suicide (n = 3) Cirrhosis (n = 2) Auto accident (n = 3) Malnutrition (n = 1)
AIDS(n= Unknown
213.0± 3 18.0 12.3 456.0
Year after operation (n=42)
148 (96-270)
2
Deaths and perioperative an incidence over l%*
metabolism
Before operation (n=42)
*
18)
(8-104)
ifthey
of glucose
141 (91-256)
are ranges.
all ofthese
prove carbohydrate their effectiveness
TABLE
215 (140-377) 174 (97-307)
37 (6-103) 55 (14-95)
(57-177)
on measures
%
0
108 (56-222)
bypass
Mean ideal body weight
%
188 (89-256)
479)
3
Effect of the gastric
after operation Mean
Time
(n = 444) 440)
AL
TABLE
1 loss in severe
Preoperative 3 mo (n 6 mo (n
ET
1, 1990;
n
=
3.8
10.1 10.1 1.1 2.5 2.7
=
1 1)
1.9 1.5 2.3
479.
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/582S/4715355 by guest on 26 February 2018
U)
0 0 .J
C.,
10’
5’
a
12
MONTHS
FIG 5. Patients who do not return have a longer history of NIDDM.
1’S
24
POST-OPERATIVE
to euglycemia
tend to be older and
SURGERY
OF
OBESITY
AND
DIABETES
585S
600
20
500
E
400
.
Lii U)
0.
15
0 0
300 -J
10
(I)
C.) 200 5
100
tc:’
,
c
T.r6 -36
-24
2
-
12
MONTHS
FIG 6. The response
; 24
36
MONTHS
48
60
72
84
96
FIG 8. The response
nism
glucose
for this
of insulin
impairment
improvement
only to weight loss, mechanisms ofthe
levels
Bariatric
surgery
offers
and diabetes mellitus. appear to be studies
or frank is not
but also antrum
NIDDM.
clear
but
to the bypass and duodenum.
unusual
The
is probably
ofthe
opportunities
mechadue
not
to study
obesity
‘
A
A
I
A
?
4
tA
A
-24
1
A
A A
ktA
AA
-36
A
A
A
9
-
2
#{212}12 MONTHS
FIG 7. The response
sugar
to the GGB.
24
36
48
60
72
84
96
POST-OPERATIVE
ofglycosylated
hemoglobin
and
subcellular
level,
a comparison
olism after gastric passing the antrum
bypass and gastroplasty and duodenum), and
ment cemia
resistance, the long-term
of the insulin will prevent
of glucose
metab-
(ie, the effect of bywhether the improve-
hyperinsulinism, complications
and hyperglyof NIDDM. #{163}3
neuroendocrine
A
t. 14
blood
to the GGB.
The most promising areas at this time of insulin action in human tissues at the
19
of fasting
POST-OPERATIVE
cellular
with either
POST-OPERATIVE
to the GGB.
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/582S/4715355 by guest on 26 February 2018
References 1. Gleysteen ii, Barboriak JJ, Sasse EA. Sustained coronary risk factor reduction after gastric bypass for morbid obesity. Am J Clin Nutr l990;5 1:774-8. 2. Sirinek KR, O’Dorisio TM, Hill D, McFee AS. Hyperinsulinism, glucose-dependent insulinotropic polypeptide, and the entroinsular axis in morbidly obese patients before and after gastric bypass. Surgery 1986;l00:781-7. 3. Kellum iM, Kuemmerle IF, O’Dorisio TM, et al. Gastrointestinal hormone responses to meals before and after gastric bypass and vertical banded gastroplasty. Ann Surg l990;2l 1:763-7. 4. Caro IF, Raju SM, Sinha MK, Goldfine ID, Dohm GL. Heterogeneity of human liver, muscle, and adipose tissue insulin receptor. Biochem Biophys Res Commun 1988; 151:123-9. 5. Dohm GL, Tapscott EB, Pories WI, et al. An in vitro human muscle preparation suitable for metabolic studies. Decreased glucose transport in muscle from morbidly obese subjects. I Clin Invest l988;82: 486-94. 6. Sinha MK, Buchanan C, Leggett N, et al. Mechanism ofIGF-I stimulated glucose transport in human adipocytes: demonstration of specific IGF-I receptors not involved in stimulation ofglucose transport. Diabetes l989;38:1217-25.
of obesity
J Pories, Kenneth G MacDonald S Swanson, Hisham A Barakat, D Long, Kevin F 0 ‘Brien, and
ABSTRACT
Since
Greenville
gastric
1980
bypass
procedure
with an acceptable
morbidity
obese patients of 1 .2%. The
weight
loss
the follow-up
period
of 10 y. The
in the
series 0GB
62 (13%)
dividuals,
141
who
reverted
with inadequate patients
who
were
were
oftheir
older
can
control
impaired. and
morbidly
only
patients. NIDDM
22 (5%)
metabolism.
diabetes
rate over
non-insulin-
was oflonger
163
in-
remained Those duration
were less likely to revert to normal values. The gastric bypass operation is an effective approach for the treatment of morbid obesity. Along with its control ofweight, the operation also controls the hyperglycemia, hyperinsulinemia, and insulin resistance of the majority frank NIDDM.
KEY
of patients
Am
WORDS
diabetes gastric
with
J C/in Nuir
Diabetes
mellitus, bypass
either
glucose impairment l992;55:582S-5S.
mellitus,
hypertension,
or
obesity,
bariatric
surgery,
Introduction Obesity
of adult
is one
ofour
Americans
most
serious
are obese
health
and,
problems.
of these,
Over
ofthis
relationship
recognized insulin
between
obesity
for centuries, resistance
is not
and
the
and
clear
eventual
diabetes,
but failure
glucose
obesity improves,
is treated along
and functional Since 1980 bypass ((3GB)
operation, 582S
concentrations
rise
successfully with
the
with amelioration
out
surgery,
the
obesity is The cause to be due
of the
of control.
3 and 7 body weight
pancreas
diabetes
usually arthritis,
effectiveness.
in Figure
3, reduces
the gastric Am
J C/in
reservoir
Nuir
creation
of a small
reservoir,
delays
emptying
with
the
gastrojejunostomy, bypasses the endocrine mechanisms of the foregut, and produces dumping when high-carbohydrate fluids
flow
directly
into
the jejunum.
The 0GB produces excellent weight loss. Based on intensive follow-up in which data on all but 17 (4%) of the 479 patients were available, Table I and Figure 4 demonstrate that maximum weight loss is achieved at ‘-24 mo and is well maintained with only a 10% weight gain even after 10 y. Most bariatric surgery can be performed with a mortality of 1%, depending
Those high
on
bariatric incidence
the
centers
risk
that
of serious
level
operate
of the
patient
on heavier
complications
such
population.
patients as cardiac
with
a
failure,
syndrome, severe diabetes, crippling arthritis, and malnutrition tend to have higher complication rates. Our perioperative morbidity and mortality are shown in Table 2. The gastric bypass is remarkably effective in the control of NIDDM. The effectiveness of that control is demonstrated in Table 3 by the correction of the abnormal concentrations of fasting glucose, fasting insulin, glycosylated hemoglobin, and the intravenous tolerance test. None ofthe patients in this small cohort require any further therapy for NIDDM. The group of 479 patients included 10 1 (2 1%) with NIDDM and another 62 (13%) who were glucose impaired (IGT). Of these 163 individuals, 14 1 reverted to normal and only 22 (5%; 21 with
NIDDM
and
1 with
these
we have performed the identical Greenville gastric procedure on 479 morbidly obese patients. The
diagrammed
the
to
morbid
of hypertension,
with
to
Figures 1 of patients. to rise with to keep up, and, thus,
When
Dohm,
to 30 mL, tightens the gastric outlet to 0.8 cm, bypasses the antrum and duodenum, and empties the chyme directly into the proximaljejunum. Functionally, the operation limits intake
trol of their carbohydrate globin > 8 mg% or fasting
a relationship
appears
meet the ever higher demand for insulin production. and 2 demonstrate this progression in five groups The data suggest that insulin production continues increasing insulin resistance until the fi cells, unable fail to reach effective insulin production on demand blood
45%
between
million are morbidly obese, exceeding their ideal by 45 kg. The most grave consequence of severe non-insulin-dependent diabetes mellitus (NIDDM).
G Lynis
Pickwickian
non-insulin-dependent
morbid
Madhur K Sinha, Nancy Leggelt-Frazier,
small The and
Of these
carbohydrate
or whose
479
in most (21%) with
glucose
to normal
control
the identical
on
and a mortality well maintained
was
dependent diabetes mellitus (NIDDM) group of 479 patients included 101 another
Jr, Elizabeth J Morgan, Prabhaker G Khazanie, Jose F Caro
performed
we have
(GGB)
and its effect on diabetes:
1992;55:582S-5S.
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/582S/4715355 by guest on 26 February 2018
7 were
22, 1 1 were taking
taking
oral
IGT)
remain
metabolism blood sugar
medication:
with
inadequate
con-
[ie, glycosylated hemo(FBS) > 125 dL/L1. Of
4 were taking
insulin
and
agents.
I From the Departments ofSurgery, Medicine, Biochemistry, Clinical Pathology, and Allied Health, East Carolina University, Greenville, NC. 2 Supported by Pfizer Pharmaceuticals/Roerig Division: “A Compar-
ison ofAmpicillin/Sulbactum vs Cefazolin for the Prevention of Infection in Morbidly Obese Following Gastrointestinal Bypass and Vertical Banded Gastroplasty,” and National Institutes ofHealth, lPOl DK36296 OlAl. 3 Address reprint requests to WI Pories, Eastern Carolina University School of Medicine, Department of Surgery, Greenville, NC 27858. Printed
in USA.
© 1992 American
Society
for Clinical
Nutrition
SURGERY ORAL
GLUCOSE
TOLERANCE
OF
OBESITY
AND
583S
DIABETES
TEST
1500
z (/,
I
C C
I 200
z 900 800
I
300 SNi
I
1W
M0t1r “#{176}r’G2!l
I
I
MI7
sl
1
FIG 1. The oral glucose tolerance test with the progression Insulin production continues to rise with increasing insulin until the islets fail due to exhaustion.
of obesity. resistance
Failure to achieve control ofthe diabetes with NIDDM was due to several causes:
in the 22/163 patients 1) failure to control
weight
such
a
because
staple
oftechnical 2) failure
line,
complications
as dehiscence
to control weight because the pouch, 3) advanced
ofthe
snacking and outeating ofthe diabetes, and 5) severity with
inadequate
had
weight
8 underwent
endoscopy,
which
that 3 had dehisced their staple lines. Patients with good glucose control were ±
1 .9 vs 49.6
± 2.8
of
patient’s 4) duration
ofthe diabetes. Ofthese 22 patients 17 had weight gain. Of these 17 who
control,
gain,
age,
FIG 3. The Greenville gastric bypass consists ofa 30-mL gastric pouch, an 0.8-cm gastrojejunostomy, and a 40-cm Roux-en-Y bypass loop.
y) and
their
diabetes
demonstrated
--8 y younger was of far
hemoglobin,
other which
and
glucose
consistently. fall
i.
not as morbidly obese. in insulin concentrations, concentrations
do
of HBA1C
the same sons
(41.8 shorter
group
for this
abetic
(Fig
7) and
of patients
show
unexpected
indices
The
duration (1.75 ± 0.69 vs 8.79 ± 2.8 y). The concentration of preoperative fasting glucose also determines the degree of postoperative control. Figure 5 compares the postoperative fasting blood glucose concentrations in NIDDM patients with preoperative FBS readings of< 120 mg% and > 120 mg%. The patients with the higher preoperative glucose values experienced greater drops in FBS than their more normal counterparts but leveled out at concentrations that were still abnormal. This response parallels the pattern seen in weight loss, ie, the heaviest patients lose the most weight, but when they level out they are still heavier than those who were The improvements
trations
is not
gastric
fasting
blood
a much
difference
sugar
wider
in the
(Fig
scatter.
behavior
bypass
is not
the
only
testinal bypasses, gastric and wiring ofteeth have
two
bariatric
procedure
that for rang-
and
the vertical banded or a Silastic band). resection
bandings, gastric been promoted,
procedures
morbidity
combined
banding
procedures
yet won
wide
di-
Since the first operation a number ofprocedures
ing from ileocolic bypass, ileojejunal bypass, various plasties, gastric bypasses, gastric resections combined
ceptable
rea-
of these
clear.
ameliorates or reverses diabetes. morbid obesity was done in 1954,
Of these,
8) on
The
have
with may
proven
mortality
gastroplasty Two other an also
wraps, adopted,
gastrowith in-
gastric balloons, and discarded.
to be effective
rates:
the
gastric
with bypass
acand
(either with a Marlex mesh collar approaches, the Scopinaro gastric intestinal
bypass
be useful
approaches
TO
YEARS
and
the but
gastric have
not
acceptance.
glycosylated not
parallel
each
WEIGHT
LOSS
10
POSTOP
In contrast
predictably
to the insulin concentrations, gastric bypass (Fig 6), the concen-
after
400
0.
300 U)
z
C.,
200
z U)
100
0
ITH NORMAl. LEAN
FIG 2. Changes
in fasting
6
1224364860728496108120 MONTHS
NORMAL
IMPAIRED
OBESE
OBESE
insulin
3
NIDOM
NIDOM
OBESE
OBESE
Fes-140
with the progression
of obesity.
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POSTOP
FIG 4. Weight loss of the clinically severely obese patients who have undergone the GOB over the last 10 y. The maximum loss usually occurs at about 24 mo and the weight is well maintained over the subsequent 8 y.
PORIES
584S TABLE Weight
obesity
weight
Mean
excess
weight
IOSt
kg
=
=
l2mo(n=416) 24 mo (n = 36 mo (n = 48 mo(n = 60 mo (n = 72 mo (n = 84 mo (n = 96mo(n= 108 mo (n = l2Omo(n=
SValues
322) 247)
95 (56-200) 84(47-180) 82 (48-166) 88 (53-184)
221)
89(52-194)
62(-22-l12)
214)
90
(48-194)
62 (-6-1
167)
91
(55-181)
59
144)
92 (51-171)
59 (-10-109)
151 (94-273)
105)
90(59-156)
57(11-93)
149(105-259)
58)
92
57 (7-95)
148 (104-276)
18)
90(63-145)
54(16-105)
147(97-197)
in parenthess
Virtually
154 (104-282)
71(13-124) 73 (9-1 16) 65 (-8-108)
136(85-268)
144(87-279)
133 (88-248)
operations,
effect
metabolism as well. Detailed in the treatment of NIDDM
(86-263)
145
complications
after
the 0GB
Complication
weight
loss,
data
regarding
im-
is, however,
operation
with
Incidence %
Deaths Perioperative (n = 6) Sepsis(n = 5) Pulmonary embolus (n = 1) Late deaths (over 10 y) (n = 16) Sepsis(n = 1) Myocardial
Fastingbloodglucose(mg%) Fasting insulin (pmol/L) Glycosylated hemoglobin Maximum insulin release
Glucose
disappearance
1.3
sparse. Gleysteen diabetic patients the amelioration
mechanism
1, 1980-April
±
± ± ±
8.0 6.0 0.6 90.0 0.07
reported
the
improvement
of nine
of the antrum
and
duodenum
may
also
be a major
factor. The limitation in the length of this abstract prevents the inclusion of the extensive basic science studies of insulin action in our morbidly obese patients conducted by Caro and his associates (4-6) at East Carolina University. The interested reader is referred to the bibliography for key references to this research. In summary, the gastric bypass operation is an effective apfor the treatment
of weight,
ofmorbid
the operation and
also
insulin
Post-op (p,’s.
20
obesity.
controls
resistance
GGB
NIDDM
Along
the
with
Patient
its control
hyperglycemia,
of the majority
hy-
of patients
Follow-up
bs>12O,,-24)
::.,
\\ \
Avg
b-’
fl2O
fbs>120
l\\\
=
E
1)
15’
w
(n = 17) Minor wound infection (n = 48) Seroma or liquefied fat (n = 48) Dehiscence(n=5) Technical complications Subphrenic abscess (n = 12) Splenic tear (n = 13) Other postoperative complications Pneumonia (n = 9) Arrythmias (n = 7) Required perioperative reoperation (n February
0.65
et al (1)
perinsulinemia,
Wound
S
±
±
after gastric bypass of hyperinsulinism
1) (n = 1)
pernicious (n complications Severe wound infection
(%/min)
±
117.0± 84.0 6.6 372.0 0.88
and Sirinek et al (2) reported and diabetes in another group of 12 morbidly obese. The best comparison between two bariatric operations was reported by Sugerman’s group (3) who studied 16 morbidly obese patients, randomized either to a gastric bypass (n = 9) or vertical banded gastroplasty (n = 7). His data demonstrate that the gastric bypass was more effective in producing weight loss and in the control of hyperinsulinemia and hyperglycemia than the vertical banded gastroplasty. We are currently conducting further studies to determine whether the difference in diabetic control between the two operations is due solely to weight loss or, as we suspect, the bypass ofthe endocrine
proach 3.4
infarction
Anemia,
rate (%) (pmol/L)
15.0 42.0 1. 1 66.0 0.08
±
I ± SD.
Cancer Liver(n= I) Larynx (n = 1) Suicide (n = 3) Cirrhosis (n = 2) Auto accident (n = 3) Malnutrition (n = 1)
AIDS(n= Unknown
213.0± 3 18.0 12.3 456.0
Year after operation (n=42)
148 (96-270)
2
Deaths and perioperative an incidence over l%*
metabolism
Before operation (n=42)
*
18)
(8-104)
ifthey
of glucose
141 (91-256)
are ranges.
all ofthese
prove carbohydrate their effectiveness
TABLE
215 (140-377) 174 (97-307)
37 (6-103) 55 (14-95)
(57-177)
on measures
%
0
108 (56-222)
bypass
Mean ideal body weight
%
188 (89-256)
479)
3
Effect of the gastric
after operation Mean
Time
(n = 444) 440)
AL
TABLE
1 loss in severe
Preoperative 3 mo (n 6 mo (n
ET
1, 1990;
n
=
3.8
10.1 10.1 1.1 2.5 2.7
=
1 1)
1.9 1.5 2.3
479.
Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/582S/4715355 by guest on 26 February 2018
U)
0 0 .J
C.,
10’
5’
a
12
MONTHS
FIG 5. Patients who do not return have a longer history of NIDDM.
1’S
24
POST-OPERATIVE
to euglycemia
tend to be older and
SURGERY
OF
OBESITY
AND
DIABETES
585S
600
20
500
E
400
.
Lii U)
0.
15
0 0
300 -J
10
(I)
C.) 200 5
100
tc:’
,
c
T.r6 -36
-24
2
-
12
MONTHS
FIG 6. The response
; 24
36
MONTHS
48
60
72
84
96
FIG 8. The response
nism
glucose
for this
of insulin
impairment
improvement
only to weight loss, mechanisms ofthe
levels
Bariatric
surgery
offers
and diabetes mellitus. appear to be studies
or frank is not
but also antrum
NIDDM.
clear
but
to the bypass and duodenum.
unusual
The
is probably
ofthe
opportunities
mechadue
not
to study
obesity
‘
A
A
I
A
?
4
tA
A
-24
1
A
A A
ktA
AA
-36
A
A
A
9
-
2
#{212}12 MONTHS
FIG 7. The response
sugar
to the GGB.
24
36
48
60
72
84
96
POST-OPERATIVE
ofglycosylated
hemoglobin
and
subcellular
level,
a comparison
olism after gastric passing the antrum
bypass and gastroplasty and duodenum), and
ment cemia
resistance, the long-term
of the insulin will prevent
of glucose
metab-
(ie, the effect of bywhether the improve-
hyperinsulinism, complications
and hyperglyof NIDDM. #{163}3
neuroendocrine
A
t. 14
blood
to the GGB.
The most promising areas at this time of insulin action in human tissues at the
19
of fasting
POST-OPERATIVE
cellular
with either
POST-OPERATIVE
to the GGB.
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References 1. Gleysteen ii, Barboriak JJ, Sasse EA. Sustained coronary risk factor reduction after gastric bypass for morbid obesity. Am J Clin Nutr l990;5 1:774-8. 2. Sirinek KR, O’Dorisio TM, Hill D, McFee AS. Hyperinsulinism, glucose-dependent insulinotropic polypeptide, and the entroinsular axis in morbidly obese patients before and after gastric bypass. Surgery 1986;l00:781-7. 3. Kellum iM, Kuemmerle IF, O’Dorisio TM, et al. Gastrointestinal hormone responses to meals before and after gastric bypass and vertical banded gastroplasty. Ann Surg l990;2l 1:763-7. 4. Caro IF, Raju SM, Sinha MK, Goldfine ID, Dohm GL. Heterogeneity of human liver, muscle, and adipose tissue insulin receptor. Biochem Biophys Res Commun 1988; 151:123-9. 5. Dohm GL, Tapscott EB, Pories WI, et al. An in vitro human muscle preparation suitable for metabolic studies. Decreased glucose transport in muscle from morbidly obese subjects. I Clin Invest l988;82: 486-94. 6. Sinha MK, Buchanan C, Leggett N, et al. Mechanism ofIGF-I stimulated glucose transport in human adipocytes: demonstration of specific IGF-I receptors not involved in stimulation ofglucose transport. Diabetes l989;38:1217-25.
