Personally, I don't care ...
Obesity Surgery, 8, 67-72
Biliopancreatic Diversion Preserving the
Stomach and Pylorus in the Treatment of
Hypercholesterolemia and Diabetes Type II:
Results in the First 10 cases
Giuseppe Noya MD; Maria Laura Cossu MD; Massimiliano Coppola MD;
GianCarlo Tonolo MD'; Maria Filippina
Matte0 Ruggiu MD
Cattedra di Chirurgia d'lkgenza e Clinica Chirurgica
Metabolismo e Clinica Medica, Facolta' di Medicina
Background: Besides weight loss Scopinaro's op-
eration produces correction of hypercholesterolemia
and noninsulin dependent diabetes mellitus in all
patients who suffer from these conditions. These
results encouraged us to perform biliopancreatic
diversion (BPD) without gastric resection, thus pre-
serving the functions of the stomach and pylorus in
moderately overweight patients with hypercholester-
olemia associated with diabetes type II and hyper-
triglyceridemia.
Methods: Between March 1996 and July 1997 we
performed BPD without gastric resection on 10
moderately overweight patients [mean body mass
index (BMI) = 33.2 kg/m2]. All patients had suffered
from hypercholesterolemia and hypettriglyceridemia
for more than 5 years. Ten patients suffered from
diabetes type II; four of them had had insulin
treatment or oral anti-diabetic agents; the other pa-
tients all had hyperglycaemia in the fasted state and
diabetes confirmed by preoperative oral glucose
tolerance test (OGlT). Five patients suffered from
hypertension.
Results: In all patients, cholesterol and triglyceride
levels returned to normal within the first postopera-
tive month. Glycemia also stabilized at normal values
in nine patients within the early weeks after surgery.
One patient who took 70 U of insulin reduced his
daily intake to 35 U 2 months postoperatively. In all
patients blood pressure returned to normal. Weight
loss was predictably slight (lo-15 kg).
Conclusions: Our experience with the procedure
found that this new method seems to be as effective
in controlling lipidic metabolism and diabetes II as
the original version of BPD. As expected, weight loss
is only moderate, so that the modified BPD is not
suitable for very obese patients. 0 1998 Rapid Science
Ltd.
Correspondence to: Giuseppe Noya, via Ft. Morandi 5, 07100
Sassari -Italy. Tel: (+39) 79 228224: fax: (+39) 79 228394.
0 1998 Rapid Science Ltd
Angius MD'; Enrico Fais MD;
Generale, and ICattedra di Malattie de1
e Chirurgia -Universita' di Sassari -Italy
Key words: Biliopancreatic diversion, diabetes, hyper-
tension, morbid obesity, serum lipids and cholesterol,
surgery.
Introduction
The results of Scopinaro's surgical method for
treating morbid obesity are well-known? As Dr.
Scorpinaro points out the main weight loss is
obtained in the first 12 months postoperation, due
to the effect of gastric resection and consequent
forced reduction in food intake. The reduction in
body weight is maintained because the biliopan-
creatic diversion (BPD) causes the selective malab-
sorption of starches and fat in particular, resulting
in a further slow weight loss that can be controlled
by changes in the diet.
Besides weight reduction, however, Scopinaro's
operation produces a series of beneficial effects on
other diseases directly associated with morbid
obesity. Hypercholesterolemia and diabetes type II
were corrected in all patients suffering from these
conditions within 30-40 days of the operation.
Hyperuricemia, hypertension and hypertriglycer-
idemia also returned to normal in 90% of cases
within 4-8 months.
These results prompted us to perform BPD
without gastric resection, preserving the stomach
and pylorus (Figure 1) on moderately overweight
patients suffering from hypercholesterolemia asso-
ciated with diabetes and hypertriglyceridemia.
Weight loss was predictably slight but easily
controllable since the gastric function was totally
Obesity Surgery, 8, 1998 67
Noya et al.
Figure 1. Biliopancreatic diversion with pylorus-preser-
ving technique (i.e. duodenal switch without restrictive
gastric surgery).
preserved, while at the same time, the selective
malabsorption of fat and starches corrected hy-
percholesterolemia, hypertriglyceridemia, diabetes
and arterial hypertension.
Materials and Methods
Between March 1996 and July 1997 we performed
BPD with preservation of the stomach and pylorus
in 10 moderately overweight patients: five males
and five females, mean age 52.1 years (range 40-
62 years); mean weight 85.2 kg (range 64-106 kg);
mean BMI 33.20 kg/m2 (range 24.0-38.97 kg/m').
All the patients had had hypercholesterolemia
and hypertriglyceridemia for over 5 years (choles-
terolemia = 260-360; triglyceridemia > 160), and
all had made various attempts to reduce cholester-
ol by changes in their diet, with little success.
Three patients had taken sinvastatin for years
without much benefit. Ten patients suffered from
diabetes mellitus, type II; two of them, both
women, had had insulin treatment for several
years, together with dietary regulation, while two
others took oral anti-diabetic agents. One woman
had taken anti-diabetic tablets and 20 U of insulin
every evening for years and another took 70 U of
insulin a day (12+23+35); two patients took two
metformin tablets (one had been taking them for 4
years and the other for 6 years). The other patients
all had hyperglycemia in the fasted state and
diabetes confirmed by preoperative oral glucose
tolerance test (OGTT). They were taking no medi-
cation but followed a hypocaloric diet. Five pa-
tients suffered from hypertension and had been
taking medication for some years (Table 1).
All the patients underwent BPD with preserva-
tion of the stomach and pylorus and end-to-end or
end-to-side duodenoileostomy (Figures 2 and 3)
(with a biodegradable ring in three cases, manual
in seven cases) and entero-enteroanastomosis
50 cm from the ileocecal valve, as in the original
technique.
Results
The postoperative course of all patients was
uneventful with canalization on the fourth day
and nutrition resumed on day 10-12. Only in four
patients was a transitory slow gastric emptying
observed when nutrition was resumed with gas-
tric stasis after eating and with subsequent spon-
taneous remission after a few days of fasting. All
patients were discharged by postoperative day 15.
Endoscopy 1 month after the operation showed, in
all cases, good functioning of the pylorus and
normal motility with no gastric or ileal ulcers.
No dietary restrictions were imposed on the
patients after the operation but they were advised
to have a varied and abundant diet, rich in fats,
starches and particularly protein.
Three patients have had a 12-month follow-up,
four patients a 6 month follow-up and three
patients a 2-3 month follow-up. The operation
had an excellent effect on glyco-lipid metabolism
and on the other parameters. Data are shown in
Table 2.
In all patients, cholesterol and triglyceride levels
returned to normal within the first postoperative
month and continued to be normal with no
restrictions in the diet. Glycemia also stabilized at
normal values in nine patients in the early weeks
after surgery. The patient who took 70 U of insulin
reduced daily intake to 35 U 2 months postopera-
tively and gave up her moderately glycoprival
68 Obesity Surgey, 8, 1998
Modified BPD and Diabetes Type II
Table 1. Preoperative data: weight, BMI, hypercholesterolemia, diabetes (and therapy), and hypertension
Patient Sex Age
(years)
Weight
(kg)
Excess
weight
BMI
(ks/m2)
Cholesterol NIDDM Hypertension
(kg)
1 M 48 98 27 33.56 290* 300 -
2 F 59 86 36 38.73 250* 132* -
Tablets 3
20 UI
3 M 45 99 36 37.21 242* 169 +
OGTT+
4 M 58 88 28 34.37 261 120 +
OGTT+
5 M 59 106 41 38.97 351 128 -
OGTT+
6 F 50 88 26 32.35 292 130 +
OGlT+
7 M 45 64 3 24.71 221 160* -
Tablets 2
8 F 62 64 9 24.71 200 120* +
70 UI
9 F 55 73 24 31.19 310 200* +
Tablets 2
10 F 40 86 34 36.28 297 120 -
OGTT+
*Patients on medical treatment (sinvastatin).
Figure 2. Operative photograph showing the duodenoileostomy.
Obesity Surgery, 8,1998 69
Nova et al.
Figure 3. Stomach X-ray on day 7 showing the intact anastomosis and the normal gastro-ileal canalization.
Table 2. Postoperative data; follow-up 2-l 8 months
Patients Follow-up Weight Excess BMI Cholesterol NIDDM Hypertension OGTT IVGTT
(months) (kg) weight (ks/m2)
(kg)
1 18 80 9 27.39 170 -Normal Altered
2 16 72 22 32.43 150 -Normal Altered
3 11 78 15 29.43 176 -Normal Normal
4 6 70 10 27.34 168 -Normal Normal
5 4 78 13 28.67 174
-
6 3 80 18 29.41 160 -
7 3 60 -1 23.16 164
-
8 5 54 -1 20.46 172 35 UI
9 2 63 14 26.92 164
-
10 2 72 20 30.30 153 -
diet; the other patient is taking no anti-diabetic measured both at home and in the hospital, had
therapy and at 1 month after the operation her already returned to < 100 mg% l-2 months after
OGTT was normal. the operation.
In four patients (three at 1 year and one at 6 Patients with hypertension no longer required
months after the operation) OGTT are normal and treatment and their blood pressure returned to
in two of these patients the i.v. glucose tolerance normal. As regards the other parameters, excellent
test was also within normal values. It-r the other results were achieved for sideremia, calcemia and,
patients (folk\w-up at under 6 months) the gly-in particular, proteinemia (2 7 mg%) and albumi-
cemia value in the fasting state and after meals, nemia (> 4%). A mean weight loss of lo-15 kg
70 Obesity Surgery, &I998
was observed in the first 3 months after the
operation and weight remained stable 1 year later.
Mean BMI in three patients was 30.50 kg/m2 after
1 year.
Complications included one case of pulmonary
embolism at postoperative day 20, caused by
occlusion of a branch of the right pulmonary
artery and which responded to thrombolytic treat-
ment. In only one case was a second operation
necessary to treat an obstruction due to stenosis of
the duodenoileostomy made from a biodegradable
ring (digital transpyloric dilatation).
All patients took 300 mg ranitidine for 6 months
after the operation in order to prevent anastomotic
ulcers.
Discussion
Various methods of surgical management of non-
insulin dependent diabetes mellitus and hyperch-
olesterolemia in obese patients have been reported
in recent years.2 These attempts became more
frequent after it was found that some operations
to treat morbid obesity had the important second-
ary effect of correcting, to a greater or lesser
extent, hypercholesterolemia and the hyperglyce-
mia sometimes associated with it.3-10
It is clear from the literature that the operations
to treat morbid obesity which also correct hy-
percholesterolemia and hyperglycemia are mainly
biliointestinal bypass procedures, in particular
Scopinaro's BPDi and the distal gastric bypass.
We agree with Scorpinaro that gastric resection
plays an essential role in the initial and most
marked weight loss, and cannot be replaced or
modified in morbidly obese patients.
Our short-term data suggest that a patient with
serious hypercholesterolemia, with or without
hyperglycemia, and with BMI not higher than
38-40 kg/m2, could undergo BPD with preserva-
tion of the stomach and pylorus. The procedure
that we performed was the same as Scopinaro's
with regard to the length of intestine making up
the alimentary loop and the common tract. It
differed in that instead of resecting the stomach
and making a gastroileostomy, we transected the
duodenum and made a duodenoileostomy (Fig-
ures 2 and 3).11,12 A cholecystectom, -rrqs done as
a prophylactic measure. In two cases we also
performed super selective vagotomy in order to
prevent ileal anastomotic ulcers.
Our 10 patients had a lo-15 kg reduction in
body weight in the first month after the operation,
Modified BPD and Diabetes Type II
and 6-12 months later they are maintaining the
reduced weight with an entirely unrestricted diet,
and are taking no medication. Hypercholesterole-
mia and hyperglycemia values went right down
after the operation.
It is possible, but needs testing, that a more or
less moderate restriction in sugar intake would
bring about a further loss in weight.
Conclusions
Our experience to date indicates that this new
method seems as effective in controlling lipid
metabolism and diabetes type II as the original
BPD procedure. As expected, weight loss is only
moderate so that the modified BPD is not recom-
mended for morbid obesity. In these cases, Scopi-
naro's method must be used unmodified despite
the metabolic problems involved, until a better
procedure is developed.
A larger number of patients with the character-
istics that we mention (BMI < 38, suffering from
hypercholesterolemia and diabetes type II) under-
going modified BPD with a longer follow-up (i.e.
at least 5 years) will show whether our encoura-
ging results are reproducible and will provide
more reliable data on recovery of pancreatic func-
tion. Studies presently being carried out indicate
that it will be possible to characterize and select
patients of normal weight who could benefit from
the operation.
One question to be carefully evaluated is
whether a super selective vagotomy should ac-
company this operation in order to prevent ileal
anastomotic ulcers.
References
1.
Scopinaro N, Gianetta E, Adami GF et al. Biliopan-
creatic diversion for obesity at eighteen years.
Surgery 1996; 119: 261-8.
2.
Buchwald H, Stoller D, Campos CT et al. Partial ileal
bypass for Hypercolesterolemia. 20 to 26 year
follow-up of the first 57 consecutive cases. Ann Surg
1990; 212: 318-31.
3.
Pories WJ, Swanson MS, Mac Donald KG et al. Who
would have thought it? An operation proves to be
the most effective therapy for adult-onset diabetes
mellitus. Ann Surg 1995; 222: 339-52.
4.
Smith SC, Edwards CB, Goodman GN. Changes in
diabetic management after Roux-en-Y gastric by-
pass. Obes Stlrg 1996; 6: 345-8.
Obesity Surgery, 8, 1998 71
Noya et al.
5. Pories
WJ. Why does the gastric by-pass control type
2 diabetes mellitus? Obes Surg 1992; 2: 303-13.
6.
Castagneto M, De Daetano A, Mingrone G et al.
Normalization of insulin sensitivity in the obese
patient after stable weight reduction with biliopan-
creatic diversion. Obes Surg 1994; 4: 161-8.
7. Jensen
K, Mason EE, Scott DH. Changes in the
postoperative hypoglycemic and anti-hypertensive
medication requirements in morbidly obese diabetic
patients after vertical banded gastroplasty. Obes Surg
1991; 1: 114 (abstract).
8. Sanderson
J, Deitel M, Bojm MA. The handling of
glucose and insulin response before and after weight
loss with jejunoileal by-pass. JPEN 1983; 7: 274-6.
9. Deitel M, Sidhu I'S, Stone E. Effect of vertical
banded gastroplasty on diabetes in the morbidly
obese. Obes Surg 1991; 1: 113-4 (abstract).
10.
Long S, Swanson MS, Pories WJ et al. Gastric bypass
surgery prevents the development of overt NIDDM
in patients with 'occult' NIDDM. Obes Surg 1996; 6:
307 (abstract).
11.
Baltasar A, Escrivh C, Mire J et al The duodenal
Switch in bariatric surgery. Obes Surg 1996; 6: 302
(abstract).
12.
Vassallo C, Negri L, Della Valle A et al. PBD +
transitory gastroplasty preserving duodenal bulb: 3
year's experience. ObesStlrg 1996; 6: 303 (abstract).
(Received 6 October 1997; accepted 22 November 1997)
72 Obesity Surgey, 8, 1998
Restoration of Euglycemia and Normal Acute Insulin
Response to Glucose in Obese Subjects With Type 2
Diabetes Following Bariatric Surgery
Eftihia V. Polyzogopoulou,1 Fotios Kalfarentzos,2 Apostolos G. Vagenakis,1
and Theodore K. Alexandrides1
Insulin resistance and loss of glucose-stimulated acute
insulin response (AIR) are the two major and earliest
defects in the course of type 2 diabetes. We investigated
whether weight loss after bariatric surgery in patients
with morbid obesity and type 2 diabetes could restore
euglycemia and normal AIR to an intravenous glucose
tolerance test (IVGTT). We studied 25 morbidly obese
patients--12 with type 2 diabetes, 5 with impaired
glucose tolerance, and 8 with normal glucose tolerance
(NGT)--before and after a biliopancreatic diversion
(BPD) with Roux-en-Y gastric bypass (RYGBP). Twelve
individuals with normal BMI served as control subjects.
Twelve months after surgery, in the diabetes group, BMI
decreased from 53.2
2.0 to 29.2
1.7 kg/m2, fasting
glucose decreased from 9.5
0.83 to 4.5
0.13 mmol/l,
and fasting insulin decreased from 168.4
25.9 to
37.7
4.4 pmol/l (mean
SE; P < 0.001). AIR, the mean
of insulin concentration at 2, 3, and 5 min over basal in
the IVGTT, increased by 770 and 935% at 3 and 12
months after surgery, respectively (from 24.0
22.7 to
209
43.4 and 248
33.1 pmol/l, respectively; P <
0,001). Conversely, in the NGT group, the AIR decreased
by 40.5% (from 660
60 to 393
93 pmol/l; P
0.027) 12 months after surgery. BPD with RYGBP performed
in morbidly obese patients with type 2 diabetes
leads to significant weight loss, euglycemia, and normal
insulin sensitivity; but most importantly, it restores a
normal -cell AIR to glucose and a normal relationship
of AIR to insulin sensitivity. This is the first study to
demonstrate that the lost glucose-induced AIR in patients
with type 2 diabetes of mild or moderate severity
is a reversible abnormality. Diabetes 52:1098-1103,
2003
From the 1Department of Internal Medicine, Division of Endocrinology,
University of Patras Medical School, Patras, Greece; and the 2Nutrition
Support and Morbid Obesity Clinic, Department of Surgery, University of
Patras Medical School, Patras, Greece.
Address correspondence and reprint requests to Theodore K. Alexandrides,
Associate Professor of Medicine, Department of Internal Medicine, University
Hospital of Patras, Rion, 26500, Greece. E-mail: [email protected].
Received for publication 17 October 2002 and accepted in revised form 11
February 2003.
AIR, acute insulin response; BPD, biliopancreatic diversion; FFM, fat-free
mass; IGT, impaired glucose tolerance; IVGTT, intravenous glucose tolerance
test; NGT, normal glucose tolerance; OGTT, oral glucose tolerance test;
QUICKI, Quantitative Insulin Sensitivity Check Index; RYGBP, Roux-en-Y
gastric bypass.
© 2003 by the American Diabetes Association.
Epidemiological studies have shown that obesity
is a significant risk factor for type 2 diabetes and
that 41% of morbidly obese patients have abnormal glycemic control (1). Insulin resistance is
more pronounced in obese subjects with type 2 diabetes
(2,3). It has been shown that progression from normal to
impaired glucose tolerance and diabetes is associated with
a reduction in insulin sensitivity and a progressive decrease of the acute insulin response (AIR) to glucose,
which is lost at the onset of diabetes (4,5). Moderate
weight loss following a hypocaloric diet can improve
insulin action and secretion, but the effect is rather weak
(6). Metabolic control has been shown to improve the
defect of early insulin response only minimally or partially
(3,7,8).
Individuals with morbid obesity and type 2 diabetes
benefit from weight loss, as this allows better glycemic
control and modifies the coexisting risk factors for coronary heart disease, namely hypertension, dyslipidemia,
insulin resistance, sleep apnea, and other comorbidities
that constitute the metabolic syndrome (9-15). Although
weight loss can be achieved by low-calorie diet, exercise,
behavior modification, and medical treatment, late weight
gain has been an almost universal problem. Conversely
Roux-en-Y gastric bypass (RYGBP) maintains a weight
loss of 33% of body weight for 10 years, a result
associated with normalization of glucose levels in patients
with impaired glucose tolerance (IGT) and type 2 diabetes,
in the vast majority of the cases (1,9-16). It also normalizes insulin action and secretion in normal glucose tolerant
subjects with morbid obesity (17,18). To our knowledge,
there are no other antidiabetic therapies that can produce
such effective and long-term glycemic control.
The purpose of the present study was to investigate
whether weight loss after gastric bypass can correct the
AIR to glucose in morbidly obese patients with type 2
diabetes.
RESEARCH DESIGN AND METHODS
Subjects. Twenty-five patients with morbid obesity were included in the
study: 12 with type 2 diabetes, 5 with IGT, and 8 with normal glucose tolerance
(NGT) who underwent a biliopancreatic diversion (BPD) with RYGBP. All
consecutive patients with diabetes and IGT who agreed to participate were
included in the study. The patients with NGT were selected to match the other
two groups with regard to BMI, age, and sex. Two of the diabetic patients were
on oral hypoglycemic agents that were discontinued 1 month before evaluation, and the other patients had hyperglycemia in the fasting state. The
DIABETES, VOL. 52, MAY 2003
E.V. POLYZOGOPOULOU AND ASSOCIATES
TABLE 1
Characteristics of the control subjects and the patients in the diabetes group
Diabetes group
Control subjects Preoperative 3 months 6 months 12 months
n 12 11 11 11 11
M/F 3/9 2/9
Age (years) 36.8
3.0 40.1
2.5
Weight (kg) 64.5
3.0 143.3
9.5 112.5
7.0 94.9
6.4 77.8
4.5
BMI (kg/m2) 22.3
0.5 53.2
2.0 41.7
1.4 35.3
1.6 29.2
1.7
FFM (kg) 75.3
2.9 65.5
5.0 61.9
5.5 55.1
4.7
Fat mass (kg) 60.9
2.9 45.6
3.0 33.1
2.5 22.6
3.4
Fasting glucose (mmol/l) 4.7
0.11 (4.2-5.3) 9.5
0.83 (6.9-15.5) 5.1
0.17 (4.2-5.9) 4.7
0.13 (4.1-5.3) 4.5
0.13 (3.9-5.1)
Fasting insulin (pmol/l) 44.4
6.0 168.4
25.9 55.3
9.1 33.5
6.1 37.7
4.4
QUICKI 0.365
0.007 0.278
0.007 0.357
0.015 0.396
0.019 0.378
0.011
1st phase insulin (pmol/l) 332.4
39.6 24.0
22.7 208.8
43.4 261.8
40.4 248.5
33.1
2nd phase insulin (pmol/l) 207.0
18.6 410.9
57.1 235.9
43.2 172.2
30.2 127.6
22.5
Data are means
SE (range) unless otherwise indicated.
duration of diabetes ranged from 3 to 5 years. Six of the 12 diabetic patients,
4 of the 5 IGT patients, and 2 of the 8 NGT patients had first-degree relatives
with a history of diabetes. The diagnosis of diabetes, IGT, or NGT was
established by a 75-g oral glucose tolerance test (OGTT), according to the
criteria of the American Diabetes Association (19), 1 month after the initial
evaluation. Twelve subjects with normal OGTT and BMI, matched to the
diabetes group for age and sex, served as normal control subjects. All subjects
were asked to consume a diet ri*****arbohydrates for 3 days before testing.
The patients were in good health and gave informed consent before surgery.
The basic characteristics of the patients are summarized in Tables 1 and 2.
Only 11 of the 12 patients in the diabetes group are shown in Table 1; because
one of the patients had fasting insulin levels 13.5 standard deviations above
the mean of the group, her data were not included in the statistical analysis
and are discussed separately.
Surgery. BPD with RYGBP was constructed with a gastric pouch 15
5 ml,
a biliopancreatic limb 150-200 cm, a common limb 100 cm, and an alimentary
limb composed of the remainder of the small intestine (16). Cholecystectomy
and appendectomy were performed in all patients. Postoperatively during the
first month, the patients consumed a liquid diet of 600-800 kcal/day composed
of 50% carbohydrates, 30% protein, and the remainder lipids. For the
next 2 months, they consumed a regular diet of similar composition containing
1,000 -1,200 kcal/day and increasing gradually to 1,500 -2,000 kcal/day during
the 1st year.
AIR to glucose. Intravenous glucose tolerance tests (IVGTTs) were carried
out preoperatively and 3, 6, and 12 months postoperatively. At 8:00 -9:00 A.M,
after a 12-h overnight fast, blood samples were collected at 10 min,
immediately before the infusion of 35 g glucose (35% wt/vol, over 2 min), and
2, 3, 5, 10, 20, and 30 min after the end of glucose infusion. The first phase of
insulin or acute insulin response was calculated as the difference ()ofthe
mean insulin concentration at 2, 3, and 5 min minus the mean insulin
concentration at -10 and 0 min of the test.
Insulin sensitivity. The Quantitative Insulin Sensitivity Check Index
(QUICKI) was used to assess insulin sensitivity according to the formula
1/(log [fasting insulin]
log [fasting glucose]). This method of insulin
sensitivity estimation is considered reliable and correlates very well with the
hyperinsulinemic isoglycemic glucose clamp, especially in the obese population
(r
0.89) (20 -22).
Body composition. The percentages of body fat (fat mass) and fat-free mass
(FFM) were determined by bioelectrical impedance (TANITA Body Composition
Analyzer, Tokyo, Japan).
Assays. Serum glucose was assayed by the glucose oxidase method within 1 h
of sample collection, using an automatic analyzer (Olympus, AU640, Medicon).
Serum samples were stored at 40°****il they were assayed for insulin
by a micro particle enzyme immunoassay (Abbott IMX System, Dainabot,
Tokyo, Japan). This assay is specific for insulin and does not recognize
proinsulin. Intra-and interassay coefficients of variation were 3.1 and 3.8%,
respectively, and the sensitivity of the method was 6.0 pmol/l.
Statistical analysis. Student's t test was used for parametric and Mann-
Whitney U test for nonparametric evaluation of differences between groups.
Paired t test was used for evaluation of differences between time points within
the same group during the follow-up. Statistical significance was set at P
0.05.
RESULTS
Preoperatively. The three groups with morbid obesity
had similar BMI, which was higher than that of the control
group (P
0.01). Fat mass and FFM were also similar
among the three surgical groups (Tables 1 and 2). The
diabetes group had a higher waist-to-hip ratio than the
NGT group, but it did not reach statistical significance
(0.962
0.029 vs. 0.880
0.028, P
0.07).
The diabetes and IGT groups had higher fasting serum
glucose (P
0.01) and higher fasting plasma insulin
concentrations (P
0.05) than the NGT and control
groups (Tables 1 and 2). The NGT group had higher fasting
insulin (P
0.05) but similar fasting glucose to that of
control subjects. Insulin sensitivity, as expressed by the
QUICKI, was reduced in the three surgical groups compared
with control subjects (P
0.005), but the NGT
group was less insulin resistant than the diabetes and IGT
groups (P
0.001) (Tables 1 and 2).
AIR was absent in 8 of the 11 subjects in the diabetes
group and substantially reduced in the other 3 subjects
(Table 1, Fig. 1A). The IGT group had a reduced response
(P
0.001) (Table 2, Fig. 2). When AIR was plotted against
insulin sensitivity in either group and was compared with
the control group (Fig. 3), it was noted that AIR was very
diminished for the degree of insulin resistance in the IGT
group and virtually absent in the diabetes group. In
contrast, the NGT group had two times greater AIR than
control subjects (P
0.001) (Table 2, Fig. 2), but this
response was appropriate for their insulin resistance (Fig.
3).
The second phase of insulin secretion, calculated as the
mean of the total insulin concentration at 10, 20, and 30
min or as the area under the curve, was greatly increased
(200%) in all surgical groups compared with control
subjects (P
0.05, Tables 1 and 2).
Postoperatively. Four and two of the eight patients in the
NGT group missed their 3-month and 6-month appointments,
respectively. All patients were studied 12 months
postoperatively. Body weight decreased significantly in all
patients. All surgical groups showed similar decreases in
BMI (24 kg/m2 for the diabetes, 21.5 for the IGT, and 18.2
for the NGT group) at the end of the 1st year (Tables 1 and
2). The decline of BMI was greater during the first 3
DIABETES, VOL. 52, MAY 2003
TABLE 2Characteristics of the patients in the IGT and NGT groups
IGT group NGT group
Preoperative 3 months 6 months 12 months Preoperative 3 months 6 months 12 months
n 55558468
M/F 0/5 0/8
Age (years) 37.8
4.3 34.1
3.3
Weight (kg) 125.7
10.5 96.6
9.1 83.5
9.3 74.4
7.8 124.9
6.2 100.7
5.2 88.4
5.0 77.9
4.8
BMI (kg/m2) 52.2
3.7 39.8
4.6 34.4
4.8 30.7
3.4 46.6
1.8 36.7
1.7 33.0
1.9 28.4
1.7
FFM (kg) 65.2
4.5 61.1
3.9 55.8
3.5 54.5
2.3 65.1
2.5 57.8
1.9 54.8
1.6 55.6
1.5
Fat mass (kg) 60.6
7.0 35.3
7.3 27.7
8.0 19.8
6.5 59.3
4.0 43.0
3.6 33.6
3.7 22.3
3.7
Fasting glucose (mmol/l) 6.1
0.19 (5.6-6.6) 4.2
0.29 (3.1-4.7) 4.4
0.23 (3.7-4.9) 4.5
0.30 (3.8-5.6) 4.9
0.12 (4.3-5.4) 4.3
0.16 (3.9-4.7) 3.9
0.12 (3.5-4.3) 4.1
0.08 (3.8-4.5)
Fasting insulin (pmol/l) 172.2
17.4 48.0
18.6 40.2
13.8 49.2
14.4 79.1
13.6 45.7
3.6 33.9
7.7 34.6
4.4
QUICKI 0.286
0.005 0.378
0.018 0.416
0.034 0.377
0.028 0.33
0.007 0.360
0.007 0.396
0.015 0.385
0.009
1st phase insulin (pmol/l) 276.0
51.6 246.6
55.2 392.4
147.0 372.6
87.0 659.6
60.2 356.4
23.3 428.8
126.9 393.1
92.8
2nd phase insulin (pmol/l) 532.2
120.6 272.4
87.0 246.6
102.6 243.6
78.6 429.3
86.0 206.4
36.6 237.9
89.9 167.7
40.9
Data are means
SE (range) unless otherwise indicated.
months following surgery and continued to decline thereafter
at a slower rate for the rest of the 1st year. All
surgical groups also showed a significant and similar
decrease in fat mass and FFM postoperatively (Tables 1
and 2), and there were no cases of hypoalbuminemia or
other signs of malnutrition. The postoperative decrease in
fat mass was proportional to the preoperative fat mass
(r
0.91, P
0.006) in the diabetes group, but not in the
other two groups.
All patients in the diabetes group had normal fasting
glucose 3 months after the operation. Fasting plasma
insulin concentration declined significantly in all groups
during the early postoperative period and became normal
3 months after surgery (Tables 1 and 2). Insulin sensitivity
improved quickly and became normal in all surgical
groups after the 3rd postoperative month (Tables 1 and 2).
AIR was restored the 3rd postoperative month in all
patients in the diabetes group and continued to improve
further during the rest of the 1st year (Fig. 1B-D and Fig.
2). The IGT group also showed an improvement of AIR
postoperatively (Fig. 2). In both groups, the relationship of
AIR to insulin sensitivity that was displaced down and far
to the left relative to the control group showed a dramatic
shift and became normal (Fig. 3). Conversely, the exaggerated
AIR in the NGT group decreased to normal levels in
parallel with insulin resistance by the third postoperative
month. AIR was similar in all groups 12 months after
surgery (Fig. 2, Table 2). Increased second-phase insulin
secretion declined gradually to control levels during the
postoperative period in all groups and below control levels
in the diabetes group (P
0.01) (Tables 1 and 2).
One diabetic patient with preoperative BMI 46 kg/m2, fat
mass 56.1 kg, and fasting glucose 8.7-9.0 mmol/l had a
fasting insulin concentration of 1,332 pmol/l, 13.5 SD
above the mean of the diabetes group. Therefore, this
patient was not included in the statistical analysis of the
data, although inclusion of the patient did not modify the
results. Three months after the operation, BMI was 36.3
kg/m2, fat mass was 42.1 kg, fasting glucose was 4.2
mmol/l, fasting insulin was 88.2 pmol/l, and the absent AIR
was above normal (670 pmol/l).
DISCUSSION
The BPD with RYGBP procedure was successful in all
patients, and weight reduction was impressive, although
the patients were still obese 1 year after the operation,
with an average BMI 30 kg/m2. There was a complete
remission of diabetes in all cases and reappearance of a
normal acute insulin response by the 3rd postoperative
month. Insulin sensitivity also became normal within the
same period, although the patients were still morbidly
obese. The abnormal relationship of AIR to insulin sensitivity
became normal. Finally, the greatly increased and
prolonged second phase of insulin secretion returned to
normal.
Our results confirm the findings of previous studies
showing the control of diabetes in morbidly obese patients
following BPD with RYGBP (9,11-14). This beneficial
effect was evident from the early postoperative period,
despite the presence of morbid obesity. Other studies had
similar results concerning weight loss and improvement in
insulin sensitivity in morbidly obese patients with normal
RESTORATION OF AIR IN TYPE 2 DIABETES
DIABETES, VOL. 52, MAY 2003
E.V. POLYZOGOPOULOU AND ASSOCIATES
glucose tolerance after bariatric surgery (17,23). In our
patients, euglycemia was restored in parallel with the
normalization of insulin sensitivity, the reappearance of a
normal AIR to glucose, and the restoration of a normal
relationship of AIR to insulin sensitivity.
Previous studies have shown that tight metabolic control
restores minimally or partially the defect in the first
phase of insulin response (7,8). Hughes et al. (24) have
reported that in obese patients with type 2 diabetes
subjected to Roux-en-Y gastrojejunostomy, the defect in
insulin secretion did not improve with weight reduction,
although insulin sensitivity did. The possible explanations
for these discrepancies between our study and the findings
of Hughes et al. (24) are the rather moderate weight loss in
their study due to the different surgical procedure, the
failure to restore euglycemia and normal insulin sensitivity,
and finally, the more severe degree and longer duration
of diabetes in their patients.
The preoperative findings in our study are consistent
FIG. 2. Acute insulin response during IVGTT. The difference ()inthe
mean insulin concentration at 2, 3, and 5 min over basal (mean SE)
is plotted. C, control subjects; DM, diabetes mellitus group; Pre,
preoperative.
FIG. 1. Insulin response after intravenous glucose
infusion (IVGTT) in normal control subjects (E)
and patients with type 2 diabetes, before gastric
bypass (A) and 3 months (B), 6 months (C), and
12 months (D) after gastric bypass.
with the changes that occur during the transition from
NGT to type 2 diabetes. The NGT group, although insulin
resistant, maintained NGT by increasing the AIR proportionally
to the degree of insulin resistance, and this is the
feature that differentiates this group from the other two
(25-28).
In contrast, the IGT group had a decreased AIR for the
degree of insulin resistance (Fig. 3). This is in agreement
with previous studies (4,25-30). Impaired AIR normalized
quickly after surgery in parallel with insulin sensitivity,
although BMI was still high. It is reasonable to assume that
the improvement in the first phase of insulin secretion
followed the normalization of insulin sensitivity.
Finally, the diabetes group was the most insulin resistant,
but AIR was absent. Because our diabetic patients
had diabetes of rather mild to moderate severity, they
maintained increased fasting insulin concentration and
increased and prolonged second-phase insulin secretion,
but they had lost the AIR to glucose. It has been shown
that AIR to glucose is lost when fasting glucose concentration
exceeds 115 mg/dl (4). It is also known that the
-cell at this stage of type 2 diabetes can respond to other
secretagogues, such as glucagon or amino acids, and that
the defect is specific to the glucose-induced AIR (3,26).
The relationship of AIR to insulin sensitivity was significantly
altered in the IGT and diabetes groups relative to
that in control subjects (Fig. 3), as previous studies have
shown (27,28,30,31). This altered relationship became
normal postoperatively, suggesting that this type of operation,
namely BPD with RYGBP, not only normalized
insulin sensitivity early after surgery, when the patients
were still very obese, but also restored a normal AIR
appropriate to the degree of insulin sensitivity. To our
knowledge, no other therapeutic intervention has had
such an effect so far.
Insulin resistance is inherited and is present many years
before the onset of type 2 diabetes (3). Obesity, usually
present in patients with type 2 diabetes, further increases
DIABETES, VOL. 52, MAY 2003
RESTORATION OF AIR IN TYPE 2 DIABETES
FIG. 3. Relationship between insulin sensitivity and acute insulin
response in patients with morbid obesity and diabetes mellitus (DM),
IGT, or NGT before and 12 months after BPD with RYGBP (mean
SE), as compared with normal control subjects (curve). Pre, preoperative.
insulin resistance, which deteriorates with age, but diabetes
develops only when the -cell fails to compensate for
the increased insulin demands (27,28). It has been shown
that amelioration of insulin resistance after treatment with
troglitazone can delay or prevent the onset of type 2
diabetes in Hispanic women at high risk for the development
of type 2 diabetes (30). Protection from diabetes, in
the same study, was closely related to the degree of
reduction in endogenous insulin requirements and the
preservation of -cell compensation for insulin resistance.
In prospective studies it has been shown that normal
glucose tolerant subjects with insulin resistance do not
develop diabetes if they can increase insulin secretion, in
particular the AIR, as insulin resistance deteriorates with
time. Alternatively, the subjects who develop IGT and later
diabetes exhibit an inappropriate progressive decrease in
the AIR to glucose in the presence of increasing insulin
resistance (27,28). A reduced AIR for the degree of insulin
resistance has been shown in subjects at high risk for the
development of type 2 diabetes, such as first-degree relatives
of patients with type 2 diabetes, older subjects,
women with a history of gestational diabetes or polycystic
ovary syndrome (25-31). Insulin secretion, when expressed
as an index normalized for insulin sensitivity, is a
very useful trait for identifying genetic predisposition to
type 2 diabetes (32). We observed that BPD with RYGBP
normalized the altered relationship of AIR to insulin
sensitivity that characterizes this category of subjects, and
this change was probably crucial for the restoration of
NGT in our patients.
The detailed mechanisms that lead to normalization of
glucose tolerance and insulin secretion in our study are
not entirely clear, however. BPD with RYGBP reduces the
total caloric intake and particularly carbohydrate consumption
in part due to dumping syndrome (33), leading to
weight loss and reduction in insulin resistance. It also
induces lipid malabsorption, reduces the elevated free
fatty acids in the circulation, and therefore reduces their
adverse effects on insulin action and secretion (34,35).
Changes in ghrelin, glucagon-like peptide-1, enterogluca
gon, and gastric inhibitory polypeptide secretion after
BPD with RYGBP have also been shown to occur and may
contribute to the same results (36 -39). Changes in fat
distribution after surgery, e.g., preferential loss of intra-
abdominal and intramyocellular fat, have a major impact
on insulin sensitivity (23). BPD with RYGBP increases
IGF-I levels and lowers leptin and pancreatic polypeptide
levels in morbidly obese patients with or without type 2
diabetes, as reviewed elsewhere (40). The restoration of
normal insulin sensitivity in our morbidly obese patients 3
months after the operation alleviated the high burden
imposed upon the -cell and possibly played a central role
in the restoration of the AIR, but it is also possible that
changes in the enteropancreatic axis played a significant
role.
In conclusion, our findings support the concept that the
diminished AIR for the degree of insulin resistance is
important for the development of IGT and diabetes. The
lack of glucose intolerance in the severely obese and
insulin-resistant NGT group that maintained an appropriately
exaggerated AIR points in the same direction. Furthermore,
our results show that the loss of glucose-
induced AIR in obese patients with type 2 diabetes of mild
or moderate severity is not permanent but reversible.
Finally, the altered relationship of AIR to insulin sensitivity
that characterizes subjects with diabetes or IGT or
subjects at high risk for the development of type 2 diabetes
becomes normal and suggests that this type of surgical
operation can be of value in these groups of patients, even
in the presence of milder degrees of obesity.
ACKNOWLEDGMENTS
This work was supported by Grant no. 2421 "K. Karatheodoris"
from the Research Council of the University of
Patras, Patras, Greece.
We thank Dr. Maria Makri and Dr. Marina Michalaki for
their valued help in hormonal analysis.
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DIABETES, VOL. 52, MAY 2003
and continue their education 
BARB 
Maybe they should call this the Ohio RNY board..... I'm from Ohio, and even though I stick mostly to the DS board, I really feel that the DS is a comparible if not argueably better surgery..... not better because I say its better, but for the clinical reasons that say it does a better job at combating obesity, and diabetes.
I've said this before, and I feel that many, but certainly not all RNYers fall into this category, but I have a few friends from work that have had the RNY. They are all happy with their decision to have the RNY. The biggest problem that I have with them is they knew nothing about the DS, and one of them didn't even know that what he had was an RNY!!! Now that is just a lack of knowledge. It's like choosing a surgeon without finding out first if he has a reputation for leaving people dead, or if he has done more than five operations since graduating from medical school.
I hope everyone has the surgery that they want, but how could anyone say they didn't want a DS if they never researched the DS in the first place. This is of course not ALL RNYers, but I will say this for the DSers that I have been able to interact with on this site, They are all well informed about both surgeries, many of them went from first choosing to have an RNY, to going with the DS. I was one of these people. Seeing more information allowed me to make an informed decision. We get alot of heat on the DS side of the mountain, and some of that is of our own making in how we respond to others, but the truth of it is that the DS is maligned in a totally unfair way by many of our brothers and sisters here in the WLS community. Dr. C's biggest problem is as I said previously, he doesnt perform the DS, and has made "HIS" standard (not THE standard) for having it so high that few would ever qualify for it.
this of course is JMHO.
kevin
Personally Kevin, Dr. C doesn't have a problem. He knows exactly what he is doing and what he wants to do. I think you all need to stay on the DS board. I researched everything and I am very happy. I'm thinking everyone here is happy with RNY so let it be. Dr. C is a wonderful doctor with extremely high standards and work ethics. All of you just let us alone. Are you all just trying to get us to be sorry for what we did? We are happy aren't you? I don't get how this all started.Let it go, Cindy
YOU let it go. You're the one starting new threads complaining about us "second guessing" a doctor that called a woman "nuts." And effectively, he called all of you "nuts" as well if you had an RNY instead of a lapband if you weren't over 50 BMI. THAT'S how this all started. We're here because one of our own came to the DS board HURT that she'd been called NUTS! But obviously, you didn't see that happen, so what do you know?
LeaAnn
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