Scopinaro N, Papadia F, Camerini G, Marinari G, Civalleri D, Gian Franco A.

Department of Surgery, University of Genoa Medical School-Azienda Ospedaliera, Universitaria San Martino, Largo Rosanna Benzi 8, Genoa, Italy. [email protected]

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD) are highly beneficial operations for type 2 diabetes mellitus (T2DM) in obese patients, leading to complete T2DM resolution in 75-90 and 97-99% of cases, respectively. In both RYGBP and BPD, the foregut is excluded from the food stream and the distal small bowel receives the food stimulation, while following BPD fat intestinal absorption is also extremely limited. This study was carried out to identify clinical features that could give insight on the different mechanisms of action on diabetes resolution. METHODS: The files of 443 severely obese patients with T2DM undergoing BPD from May 1976 to May 2007 were examined, and the presence of T2DM (fasting serum glucose >125 mg/ml) at 1-2 months, at 1 year, at 10 years, and at > or =20 years following the operation was recorded. RESULTS: The percentage of patients cured (fasting serum glucose reduced to < or =110 mg/dl, on free diet and with no therapy) was 74% at 1 month, 97% at 1 and 10 years, and 91% at > or =20 years, the 26% of uncured patients at 1 month being those with most severe preoperative T2DM. CONCLUSIONS: As the early results after BPD resemble those reported after RYGBP, it can be hypothesized that the duodenal exclusion and the distal small bowel stimulation are the first mechanisms acting in BPD, immediately after the operation, that only subsequently the myocellular fat depletion, which cannot be immediate, takes over, and that the minimal fat absorption is the mechanism accounting for the long-term results of BPD.

I'm only going to include the parts that stand out, but the full article is available here:

http://care.diabetesjournals.org/cgi/content/full/31/Supplem ent_2/S290

Diabetes Care 31:S290-S296, 2008
DOI: 10.2337/dc08-s271
© 2008 by the American Diabetes Association
 

Is Type 2 Diabetes an Operable Intestinal Disease?

A provocative yet reasonable hypothesis

Francesco Rubino, MD

From the Department of Surgery, Catholic University of Rome, Rome, Italy

	ABSTRACT

 
^... This article presents available evidence in support of the hypothesis that type 2 diabetes may be an operable disease characterized by a component of intestinal dysfunction.

 

Abbreviations: BPD, bilio-pancreatic diversion • DJB, duodeno-jejunal bypass • GIP, gastric inhibitory peptide • GLP, glucagon-like peptide • RYGB, Roux-en-Y gastric bypass

	TYPE 2 DIABETES: IS IT AN INTESTINAL DISEASE?—

 
The rapid resolution of diabetes after Roux-en-Y gastric bypass (RYGB) and bilio-pancreatic diversion (BPD) and experimental studies in rodents suggest that the control of diabetes after gastrointestinal bypass operations is a direct consequence of the rearrangement of gastrointestinal anatomy and not only the result of decreased caloric intake and weight loss. This result further supports the knowledge that the gastrointestinal tract plays an important role in energy homeostasis, consistent with the evidence that many gut hormones are involved in the regulation of glucose homeostasis.

Therefore, it is reasonable to assume that significant anatomical rearrangements of the gastrointestinal tract may cause changes in energy and glucose homeostasis, which eventually influences diabetes. However, it would be important to understand whether this occurs as the effect of changes that improve glucose homeostasis per se or as the result of reversing abnormalities of glucose metabolism. The latter hypothesis implies that the gastrointestinal tract may harbor critical mechanisms for diabetes pathophysiology.

In fact, if gastrointestinal bypass procedures worked only by enhancing a mechanism and/or signal with positive influence on insulin sensitivity and/or secretion (i.e., GLP-1, reduced glucose absorption, weight loss, etc.), one should expect that gastrointestinal bypass surgery should always improve glucose homeostasis, whether the operation is performed in diabetic or in otherwise healthy individuals. In contrast with this expectation, we observed that when DJB is performed in nondiabetic animals (Wistar rats) glucose tolerance is worse than that of matched sham-operated controls, in striking contrast with the marked improvement seen in diabetic GK rats after DJB (27). These data are consistent with the results of clinical investigations showing impairment of glucose tolerance in nondiabetic humans who have undergone surgical exclusion of the duodenum (i.e., for the treatment of peptic ulcer or gastric cancer) (28).

In summary, preventing duodenal passage of nutrients by gastrointestinal bypass operations improves glucose tolerance only in diabetic patients, whereas it is detrimental for glucose homeostasis when performed in normal subjects. These findings are consistent with the possibility that the surgical bypass of the proximal small intestine reverses a putative intestinal mechanism characteristic of diabetic patients, but not of normal individuals. Accordingly, type 2 diabetes might be characterized by a component of duodenal-jejunal dysfunction.

	TYPE 2 DIABETES: IS IT AN OPERABLE DISEASE?

 
Background data
A meta-analysis involving 136 studies for a total of 22,094 patients showed that type 2 diabetes was completely resolved in 76.8% and resolved or improved in 86.0% of patients who had undergone bariatric surgery (7). The same study showed that complete remission of diabetes occurs in 48% of patients after laparoscopic gastric banding, 84% after RYGB, and >95% after BPD (7). The remission of diabetes after RYGB and BPD is also durable, and recurrence of diabetes >10 years after surgery is rare (8). Intriguingly, whereas remission of diabetes after laparoscopic gastric banding typically occurs over several weeks to months (9), consistent with the consequences of weight loss, RYGB and BPD can cause complete remission of diabetes within days to weeks after surgery, long before substantial weight loss has occurred (4,5).

What makes bariatric surgery so effective in controlling diabetes? A simple, quite logical explanation would be that by inducing massive weight loss in patients who are morbidly obese, bariatric surgery just eliminates the condition (obesity) that puts the patient at risk for diabetes. According to this explanation, diabetes should remit only when this type of surgery is performed in obese individuals and as a consequence of substantial weight loss.

To investigate whether or not diabetes control is the result of treating obesity and inducing weight loss, we performed an experimental study in Goto-Kakizaki (GK) rats, a spontaneous nonobese model of type 2 diabetes (6). This study showed that a stomach-preserving DJB (Fig. 4) dramatically improves fasting glycemia and glucose tolerance, independent of weight loss and/or decreased caloric intake. This study was the first experimental demonstration that the anti-diabetic effect of gastrointestinal bypass surgery is not unique to obese individuals and that weight loss/decreased caloric intake cannot entirely explain why surgery improves type 2 diabetes.

Preliminary clinical studies seem to confirm these findings also in humans. Cohen et al. (10) performed DJB to treat diabetes in two patients who were non–morbidly obese. In spite of the fact that the operation did not cause significant changes in BMI and body weight, these patients had normal plasma glucose and A1C levels. Remission of diabetes in non–morbidly obese patients has also been reported after RYGB and BPD (11–13). Earlier reports also documented diabetes improvement and/or remission after gastrectomy and partial gastric resections (14), which, like DJB and RYGB, are characterized by a variable degree of bypass of the proximal small bowel.

All together, these studies show that gastrointestinal bypass operations can achieve control of diabetes by mechanisms that are independent of the treatment of obesity and surgically induced weight loss. Hence, type 2 diabetes is, per se, potentially amenable to surgical treatment.

	FROM BARIATRIC TO "DIABETES SURGERY"—

 
Using surgery explicitly to treat diabetes is a revolutionary concept and represents a disruption to current therapeutic paradigms. For this reason, many physicians might be reluctant to accept the idea of a surgical treatment of type 2 diabetes. Scientific data, however, suggest that a surgical approach to diabetes is more than a heretical suggestion.

The meta-analysis of Buchwald et al. (7) showed that RYGB results in an average 50–60% long-term excess weight loss. Hence, RYGB, and likewise other bariatric operations, rarely return patients to an entirely normal condition. Losing 50–60% of the excess weight indeed means that, in many patients, the remaining 40–50% of the excess weight is not eliminated by the operation. Technically, many patients remain overweight or frankly obese and fail to achieve "complete remission" of obesity. This is in striking contrast with the evidence that >80% of patients who undergo RYGB and >90% of those who undergo BPD experience a complete sustained remission of type 2 diabetes. Therefore, if considered only in terms of ability to induce disease remission, RYGB (and BPD) seem to be even more effective in diabetes than in obesity itself. This paradox suggests that the definition of "bariatric operations" might be inadequate to define surgical procedures that result in more than just weight loss. It would perhaps be more appropriate to consider the definition of "diabetes surgery" for these operations when they are performed in patients with type 2 diabetes, regardless of their degree of obesity. In fact, inducing diabetes remission is certainly a more important benefit than weight loss per se, even in a morbidly obese patient. Increasing evidence also shows that RYGB and BPD are capable of inducing significant changes in gut hormones and regulatory factors of energy homeostasis (15), supporting the notion that these operations are indeed truly metabolic procedures.

There is NO CURE for diabetes.  There is relief of symptoms and a reduction in blood sugar numbers.  Quoting the article:  Regarding hypercholesterolemia, hypertrigliceri-demia, and type 2 diabetes when there is a good pancreatic "reservoir", the operation seems effective in the long-term.

Do you understand what that means?  Do you know what is a pancreatic reservoir?  Here is what it mean:  Once a person is diagnosed with diabetes their pancreas already has a reduction of beta cells by 80%, and once lost those NEVER come back... if you reduce your blood glucose numbers radically you can live better on the few 20% you have left.  Most people can still function and live well for years with only 20% if their weight is nearer to normal and they maintain a strict control of the diabetes with blood sugars down in the normal ranges.  The pancreas will function nicely, but if insulin resistance is an issue, the disease remains progressive.  I get my information from presentations at the last ADA conference in San Fransisco, and available on line if you wish to learn more.

Diabetes is insidious and progressive.  Articles like this are wishful thinking.... where you might think there is a cure, but don't be taken in by an article if you truly don't understand what you read here.... there is no ability under this sun of ours to return the pancreas to full 100% operation once you have deplete the cells.  Dead and gone is just that, dead and permanently gone.  These cells don't grow back.   This organ can't support a human body that weighs 500 pounds if it is operating with only 20% of it's normal functioning pancreas... and that is what is meant by that pancreatic "reservoir" mentioned in the ad.  A human body that weighs 100 pounds can tolerate a 20% operating pancreas better than someone who weighs 500 pounds.  It's simple logic!  If you have been diagnosed with diabetes already, you probably have a lot of your beta cells already destroyed by this disease, and are living with a combination of insulin resistance along with hypercholesterolemia and hypertriglicerides.  

There is NO CURE for diabetes today any place on the face of this planet.  It will take a pancreas transplant or cloning.  And neither of them are a cure.  Just replacements.

I wanted to add one small point: 

Sad part of all of this is that these articles are using the word "cure" when all they truly mean is that being cured means being off of  medications.  It's not the same folks!   How sad for us that even researches don't know how to express what they really mean.

It's not "just" being off all medications. It is also being able to freely eat carbs without ever spiking above a normal blood glucose level. It's also about maintaining normal fasting and A1C readings. It's also about any sign of diabetes NOT returning, even if some weight is regained.

Just because you can't fix your pancreas doesn't guarantee you don't have enough pancreatic function remaining to keep you free of diabetes symptoms for the rest of your life. If you have no symptoms of diabetes, don't spike glucose levels regardless of dietary intake, and can go to a doctor you've never seen before without tellin them you'd previously been a diabetic and have them NOT be able to diagnose with diabetes, have you not been cured?

I'm glad that folks are being pro-active and testing. I see to often folks that tell me, Oh this cured me of my diabetes. They just don't want to hear is that it is still there. 

Just need to maintain it or by the time you realize something isn't going right it could be too late. So many times folks have had diabetes 10 years before they know it. Why? because it normally takes about 10 years for complications to set in.


So even if your off medications (GREAT)  still continue to periodically test - and maintain your ha1c every 6 months to be the healthiest for life!

As always, bold red added for emphasis. Thanks to kitkat24 for the heads up on this one.

University Of Minnesota / Study finds weight-loss surgery ends type 2 diabetes symptoms

U bases conclusion on 8,000 cases By Jeremy Olson
jolson@pioneerpress.com Updated: 03/02/2009 11:17:11 PM CST
 

Bariatric surgery is a virtual cure for type 2 diabetes, eliminating symptoms of the metabolic disorder in three of four patients, according to a University of Minnesota study released Tuesday.

University researchers analyzed 621 existing studies, many of which already pointed to the ability of bariatric surgery to eliminate diabetes symptoms. When looking collectively at more than 8,000 diabetics in these studies, U researchers found that 78.1 percent had no symptoms of the disease after their weight-loss surgeries.

Even among patients whose surgeries took place two years earlier, more than 74 percent reported no diabetes symptoms.

The collection of these small studies in one large analysis makes a strong statement about the effectiveness of bariatric surgery, said Dr. Henry Buchwald, a U bariatric surgeon and lead author. The results, published in the American Journal of Medicine, suggest that bariatric surgery could be used more aggressively as a front-line treatment for diabetes, Buchwald said.

"It's the best we have to offer today," he said. "That's a pretty strong statement."

The U.S. has a growing epidemic of type 2 diabetes, in which the body either produces too little insulin, which regulates blood sugar, or becomes resistant to insulin's effects. Most diabetics inject themselves with synthetic insulin to manage the disease, which can be fatal if unmanaged and also can lead to heart and kidney problems. In rare cases, diabetics receive pancreas transplants.

Bariatric surgery remains a controversial and costly approach to treating obesity. Most health plans approve the $15,000 to $25,000 procedures only for someone with a body-mass index of at least 40, or a BMI of 35 if they have related conditions such as diabetes. Some require people to fail at other weight-loss methods prior to the surgery.

The number of inpatient obesity surgeries in Minnesota increased rapidly during the past decade but peaked at 4,779 in 2004, according to the Minnesota Hospital Association. There were 3,600 in 2007.

The U analysis found certain types of surgeries were more effective at curbing diabetes. Only 57 percent of patients reported no diabetes symptoms after a banding procedure, in which an external band is tightened around the stomach to restrict food intake.

More than 95 percent of patients reported no diabetes symptoms after a duodenal switch, a more complicated procedure that shrinks the size of the stomach and bypasses the duodenum, or first segment of the small intestine.

Buchwald wouldn't call bariatric surgery a cure for diabetes, because the term implies that doctors know exactly how they are defeating a disease. In this case, doctors know that bariatric surgery works, but they don't yet know why.

Buchwald said the findings offer new directions for diabetes researchers. Learning how bariatric surgery affects this disease ultimately could lead to a true cure.

"Not only are we going to find out the mechanism of this therapy," Buchwald said, "but we may unlock what is really the basis of type 2 diabetes."

Researchers from the Mayo Clinic, East Carolina University and United BioSource Corporation also participated in the analysis.

Jeremy Olson can be reached at 651-228-5583.

Since I threw it together for a response on another forum, here are some long-term studies (thanks to Bev of www.dsfacts.com for having things organized better than I do!) - bold red added by me for emphasis:


Duodenal Switch: Long Term Results (15 Years)
Marceau et al. Nov 2007
http://www.ncbi.nlm.nih.gov/pubmed/18219767
Click here for the full article.

BACKGROUND: This report summarizes our 15-year experience with duodenal switch (DS) as a primary procedure on 1,423 patients from 1992 to 2005.

METHODS: Within the last 2 years, follow-up of these patients, including clinical biochemistry evaluation by us or by their local physician is 97%.

RESULTS: Survival rate was 92% after DS. The risk of death (Excess Hazard Ratio (EHR)) was 1.2, almost that of the general population. After a mean of 7.3 years (range 2-15), 92% of patients with an initial BMI < or = 50 kg/m2 obtained a BMI < 35 and 83% of those with an initial BMI > 50 obtained a BMI < 40. Diabetes was cured (i.e. medication was discontinued) in 92% and medication decreased in the others. The use of the CPAP apparatus was discontinued in 90%, medication for asthma was decreased in 88%, and the prevalence of a cardiac risk index > 5 was decreased by 86%. Patients' satisfaction in regard to weight loss was graded 3.6 on a basis of 5, and 95% of patients were satisfied with the overall results. Operative mortality was 1% which is comparable with gastric bypass surgery. The need for revision for malnutrition was rare (0.7%) and total reversal was exceptional (0.2%). Failure to lose > 25% of initial excess weight was 1.3%. Revision for failure to lose sufficient weight was needed in only 1.5%. Severe anemia, deficiency in vitamins or bone damage were exceptional, easily treatable, preventable and no permanent damage was documented.

CONCLUSION: In the long-term, DS was very efficient in terms of cure rate for morbid obesity and its comorbidities. In terms of risk/benefit, DS was very sucessful with an appropriate system of follow-up.

----------------------------------------------------------------------------------------------


From Hess, et al.: Biliopancreatic Diversion with a Duodenal Switch, Obesity Surgery, 8, 1998; 267-282. (This one goes a bit extreme, IMO, to say they can basically guarantee the DS will cure the type 2 diabetes, but, it's out there!)

Bariatric surgery has been known to improve or cure diabetes mellitus⁶. With the biliopancreatic bypass and the duodenal switch we have operated on 36 diabetics, all Type II, of which 18 of them are non-insulin dependent and 18 were insulin dependent. One patient was taking as high as 500 units of insulin a day, but generally they were taking insulin in the range of 40 to 50 units per day. The non-insulin dependent patients would leave the hospital after surgery taking no medication and have continued taking no medication since their surgery. The insulin dependent diabetics would occasionally take a small amount of insulin or a hypoglycemic agent for a short time, but never more than two months following surgery. All of the above patients, after a few months and up to seven years following surgery, are taking no medication of any type for their diabetes. All of them have normal blood sugars as indicated in the graph showing the pre-operative average blood sugar and the post-operative average blood sugar on all these patients up to 5 years (Figure 8). The present glycosylated hemoglobin average for this group is 5.0% (normal reference range is 4.2%-5.9%). We can say without hesitation for the obese Type II diabetic, this surgery will cure their diabetes.

Figure 8. Glucose levels of diabetics.




----------------------------------------------------------------------------------------------------



From Scopinaro N, et al.: Biliopancreatic Diversion, World J Surg. 1998 Sep;22(9):936-46. PMID: 9717419; UI: 98383147. It is a 21-year follow-up on the BPD, which is the procedure upon which the present DS is based.

OTHER BENEFICIAL EFFECTS

The other benefits obtained after BPD are listed in Table 5. The percentage of changes observed after the operation were calculated for each complication in patients with a minimum follow-up corresponding to the postoperative time after which there was generally no further substantial modification. Recovery and improvement were considered only when favorable changes were essentially maintained at all subsequent reexaminations. The observed beneficial effects are obviously not attributable to the BPD itself, but to the weight loss and/or the reduced nutrient absorption, the only two exceptions being the effects on glucose and cholesterol metabolism.

Table 5: Other beneficial effects of AHS BPD.

	minimum follow-up (mo)	disappeared (%)	improved (%)	unchanged (%)	impaired (%)
pickwickian syndrome* (2%)	1	100	-	-	-
somnolence† (6%)	1	100	-	-	-
hypertension‡ (39%)	12	81	13	6	-
fatty liver§ (46%)	24	87	9	4	-
leg stasis (31%)	12	45	39	16	-
hypercholesterolemia¶ (55%)	1	100	-	-	-
hypertriglyceridemia (33%)	12	95	5	-	-
hyperglycemia (14%)	4	100	-	-	-
diabetes mellitus (6%)	4	100	-	-	-
diabetes mellitus requiring insulin (2%)	12	100	-	-	-
hyperuricemia (16%)	4	94	-	3	3
gout (2%)	4	100#	-	-	-

(%) percent of patients with condition
* somnolence with cyanosis, polycythemia, and hypercapnia
† in absence of one or more characteristics of pickwickian syndrome
‡ systolic ³ 155, diastolic ³ 95 mm Hg, or both
§ more than 10%
 moderate or severe
¶ more than 200 mg/ml (22% more than 240 mg/ml)
# serum uric acid normalized, no more clinical symptoms

In fact, out of the 1773 (total series) AHS BPD patients with a minimum follow-up of one year, not only the 248 (14%) with preoperative simple hyperglycemia, nor only the 108 (6.1%) with type II diabetes mellitus manageable with oral hypoglycemics, but also the 32 (1.8%) patients with preoperative type II diabetes mellitus requiring insulin therapy, one year after BPD and permanently thereafter had normal serum glucose level without any medication and on totally free diet. Comprehensibly, this is accompanied by serum insulin levels normalization, as demonstrated by us in cross-sectional (22) and longitudinal (serum insulin in 53 AHS BPD subjects: preop. 18±10 mcU/ml; at 1 year 5.2±2.3; at 2 years 4.6±2.0; at 3 years 6.0±3.1; controls 6.9±2.6; ANOVA: each group vs. preop. <.0001) studies, as well as normalization of insulin-sensitivity (Table 6). Considering that about 20 percent of type II diabetes mellitus patients are not obese, and about 20 percent of formerly obese patients with type II diabetes mellitus still require insulin therapy after weight normalization by dieting, it must be concluded that simple weight loss or intraabdominal fat reduction cannot account for the observed 100 percent recovery from type II diabetes mellitus after BPD. Actually, our preoperatively diabetic patients had on the average normal serum glucose concentration already one month after operation, when the excess weight was still over 80%, this also indicating a specific action of BPD on glucose metabolism. The latter could be identified with the virtual annulment of the entero-insular axis. Indeed, serum GIP concentration shows after BPD a substantially flat curve in response to the test meal, along with normalization of basal and meal-stimulated serum insulin levels (10).

Table 6: Serum glucose and insulin concentrations and insulin sensitivity (euglycemic hyperinsulinemic clamp) in obese patients, in subjects 2-4 years after BPD and in lean controls.

		obese subjects	BPD subjects	lean controls
No.		9	6	6
glycemia (mg/dl)	mean	99.1 *	74.6	86.6 *
	range	63-116	69-81	83-92
insulinemia (mcU/ml)	mean	21.7	4.4 §	10.3 §
	range	11-41	1-13	9-12
glucose uptake (mg/kg/min)	mean	2.9	9.3 †	10.5 †
	range	1.7-7.2	6.8-11	8.5-12

U-Mann Whitney test:
* p < .01 vs. BPD subjects
§ p < .03 vs. obese patients
† p < .001 vs. obese patients

...Gasbarrini et al. (25.) submitted to HH BPD a lean young woman with familial chilomicronemia (serum triglycerides: 4500 mg/dl; serum cholesterol: 502 mg/dl) and type II diabetes mellitus (insulin 150 U/day to maintain serum glucose around 250 mg/dl). One year after operation she had gained 2 kg in weight, blood glucose was normal, serum triglycerides 380 mg/dl, serum cholesterol 137 mg/dl, on totally free diet and without any medication.

It is concluded that BPD may be effectively used for the treatment of severe type II diabetes mellitus and familial hyperlipidemia also in lean subjects.

 

Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis.

Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, Bantle JP, Sledge I.

Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA. [email protected]

BACKGROUND: The prevalence of obesity-induced type 2 diabetes mellitus is increasing worldwide. The objective of this review and meta-analysis is to determine the impact of bariatric surgery on type 2 diabetes in association with the procedure performed and the weight reduction achieved.
METHODS: The review includes all articles published in English from January 1, 1990, to April 30, 2006.
RESULTS: The dataset includes 621 studies with 888 treatment arms and 135,246 patients; 103 treatment arms with 3188 patients reported on resolution of diabetes, that is, the resolution of the clinical and laboratory manifestations of type 2 diabetes. Nineteen studies with 43 treatment arms and 11,175 patients reported both weight loss and diabetes resolution separately for the 4070 diabetic patients in these studies. At baseline, the mean age was 40.2 years, body mass index was 47.9 kg/m2, 80% were female, and 10.5% had previous bariatric procedures. Meta-analysis of weight loss overall was 38.5 kg or 55.9% excess body weight loss. Overall, 78.1% of diabetic patients had complete resolution, and diabetes was improved or resolved in 86.6% of patients. Weight loss and diabetes resolution were greatest for patients undergoing biliopancreatic diversion/duodenal switch, followed by gastric bypass, and least for banding procedures. Insulin levels declined significantly postoperatively, as did hemoglobin A1c and fasting glucose values. Weight and diabetes parameters showed little difference at less than 2 years and at 2 years or more.
CONCLUSION: The clinical and laboratory manifestations of type 2 diabetes are resolved or improved in the greater majority of patients after bariatric surgery; these responses are more pronounced in procedures associated with a greater percentage of excess body weight loss and is maintained for 2 years or more.

PMID: 19272486 [PubMed - in process]

An article about the Buchwald meta-analysis (the bold red part shows that at 2+ years post-op, RNY about 10% of patients who saw their diabetes resolved early post-op had RECURRENCE of their diabetes, while those with the DS actually had MORE cases of resolved diabetes at 2+ years post-op):

Potential For Resolving Type 2 Diabetes With Bariatric Surgery

ScienceDaily (Mar. 11, 2009) — As the incidence of obesity-induced type 2 diabetes mellitus continues to increase worldwide, medical research indicates that surgery to reduce obesity can completely eliminate all manifestations of diabetes.

In a study published in the March 2009 issue of The American Journal of Medicine, investigators analyzed 621 studies from 1990 to April of 2006, which showed that 78.1% of diabetic patients had complete resolution and diabetes was improved or resolved in 86.6% of patients as the result of bariatric surgery. The primary risk factor for type 2 diabetes is obesity, and 90% of all patients with type 2 diabetes are overweight or obese.

The dataset included 135,246 patients where 3188 patients reported resolution of the clinical and laboratory manifestations of type 2 diabetes. Nineteen studies with 11,175 patients reported both weight loss and diabetes resolution outcomes separately for the 4070 diabetic patients in those studies. Clinical findings were substantiated by the laboratory parameters of serum insulin, HbA1c, and glucose.

Researchers observed a progressive relationship of diabetes resolution and weight loss as a function of the operation performed: laparoscopic adjustable gastric banding, gastroplasty, gastric bypass, and biliopancreatic diversion/duodenal switch (BPD/DS). Gastric banding yielded 56.7% resolution, gastroplasty 79.7%, gastric bypass 80.3% and BPD/DS 95.1%. After more than 2 year post-operative, the corresponding resolutions were 58.3%, 77.5%, 70.9%, and 95.9%. In addition, the percent excess weight loss was 46.2%, 55.5%, 59.7% and 63.6%, for the type of surgery performed, respectively.

Writing in the article, Henry Buchwald, MD, PhD, Department of Surgery, University of Minnesota, states, "This systematic review and meta-analysis demonstrate that bariatric surgery has a powerful treatment effect in morbidly obese persons with type 2 diabetes; 82% of patients had resolution of the clinical and laboratory manifestations of diabetes in the first 2 years after surgery, and 62% remained free of diabetes more than 2 years after surgery (80% and 75% for the total group). Randomized clinical trials comparing surgery and medical therapies for type 2 diabetes are urgently needed. Considering the potential benefits for millions of people, such trials should assess the risk/benefit ratio of surgery in less obese (BMI 30-35 kg/m²) populations, as well as in the morbidly obese (BMI>35 kg/m²) population."

---

Journal reference:

1. Henry Buchwald et al. Weight and Type 2 Diabetes after Bariatric Surgery: Systematic Review and Meta-analysis. The American Journal of Medicine, Volume 122, Issue 3 (March 2009)