Johns Hopkins Diabetes Guide

Bariatric Surgery

Octavia Pickett-Blakely, M.D.; Mimi Huizinga, M.D.

DEFINITION

  • A frequently done, effective surgical intervention for obese individuals to reduce weight and improve obesity-related comorbidities such as diabetes. Results in weight loss by restriction of overall nutrient intake, malabsorption of nutrients, and/or a combination of restriction and malabsorption.
  • Laparoscopic adjustable gastric band: restrictive procedure that inserts a band around the proximal stomach; the band is connected to a subcutaneous port used to adjust the amount of gastric restriction provided by the band.
  • Laparoscopic sleeve gastrectomy: restrictive procedure that removes large portion of the greater curvature of the stomach leaving a stomach "sleeve" along the lesser curvature. Can be done as the first part of a duodenal switch or as a standalone procedure.
  • Roux-en-Y gastric bypass: combination restrictive and malabsorptive procedure that creates a small gastric pouch by separating the proximal and distal stomach; the proximal gastric pouch is anastamosed to a loop of jejunum ("Roux limb"), while the bypassed distal stomach and proximal small bowel ("Y limb") is anastamosed distally to the jejunum.
  • Biliopancreatic diversion (BPD) with or without duodenal switch: combination restrictive and malabsorptive procedure that creates a laparoscopic sleeve gastrectomy with remaining stomach either: 1) attached to lower portion of smaller intestine (BPD) or 2) attached to upper small intestine with creation of separate biliary loop, both of which connect to common channel of lower smaller intestine (duodenal switch).

EPIDEMIOLOGY[Top]

  • Up to 55% of all patients diagnosed with diabetes are obese[1].
  • Of an estimated 225,000 bariatric surgeries performed per annum, 15- 30% have diabetes[1].
  • Bariatric surgery can result in the resolution of type 2 diabetes in 48-98% of cases depending on the type of surgery performed[2][3].
  • Diabetes-related mortality and all- cause mortality is significantly decreased after gastric bypass[4][2].

DIAGNOSIS[Top]

  • Eligibility for bariatric surgery is established according to National Institutes of Health guidelines: BMI ≥ 40 kg/m2 or a BMI ≥ 35 kg/m2 with an obesity- related comorbidity such as diabetes, hypertension, obstructive sleep apnea, obesity hypo-ventilation syndrome, Pickwickian syndrome, severe urinary incontinence, hyperlipidemia, debilitating osteoarthritis, nonalcoholic fatty liver disease, coronary artery disease, gastroesophageal reflux disease, and pseudotumor cerebri[5].
  • In February 2011, FDA approved use of laparoscopic adjustable gastric banding for BMI ≥30 kg/m2 with an obesity-related comorbidity in response to a study presented by the manufacturer that showed significant weight loss after the surgery for persons who were mildly obese.
  • Specific coverage guidelines vary by insurance carrier (e.g. documentation of a failed trial of diet and exercise and performance of surgery at an American Society for Bariatric Surgery designated Center of Excellence).

CLINICAL TREATMENT[Top]

Glycemic control in immediate post-operative period (days 0-3)

  • Insulin requiring patients often require significantly lower doses of insulin and oral hypoglycemic agents post-operatively due to decreased oral intake.
  • With Roux-en-Y or BPD procedures, hyperglycemia may improve dramatically within several days, well before significant weight loss.
  • Advance oral intake according to institution or provider specific protocols. Most diets begin with clear liquids and advance to full liquids or pureed foods that are high in protein and low in fat and carbohydrates.
  • A combination of basal and rapid- acting prandial insulin is preferred to keep fasting blood glucose levels between 80 and 110 mg/dl and post-prandial glucose levels below 180 mg/dl.
  • Some patients only require meal-time insulin during this time period due to irregular intake and decreasing insulin requirements.
  • Doses of oral agents should be withheld or adjusted in non-insulin requiring patients. Specifically, secretagogues should be discontinued in the immediate post-operative period.

Glycemic control in the outpatient setting

  • Oral intake is advanced further from full liquids and pureed foods ultimately to a regular diet (small, frequent meals) consisting of high protein, low fat and low carbohydrate meals.
  • In patients with Type 2 diabetes, home preprandial and fasting blood glucose measurements should be performed periodically.
  • The use of insulin and/or oral agents is dictated by the patient’s home glucose measurements and often declines within 1 year of bariatric surgery (in up to 76%).
  • Most patients will be off insulin and oral agents by 3 months post-operatively.

Micronutrient deficiencies

  • Post-bariatric surgery patients are at risk for a variety of micronutrient deficiencies including: B12, iron, calcium, vitamin D, folate, B1 and others.
  • All patients receiving bariatric surgery should be started on a multivitamin with iron and calcium citrate with vitamin D after bariatric surgery.
  • Patients should be monitored regularly for micronutrient deficiencies. The frequency depends on the type of surgery. Patients undergoing laparoscopic adjustable band should be monitored annually, gastric bypass require monitoring every 3-6 months, and bilopancreatic diversion patients should be monitored every 3-6 months.
  • Although calcium is absorbed throughout the small intestine and colon, calcium containing foods (e.g. milk, cheese) may provoke bloating, cramping and diarrhea in a post-bariatric patients placing them at risk for deficiency. Calcium citrate with vitamin D is the recommended form of calcium because of increased absorption.
  • Oral B12 is often not sufficient to replete B12 deficiencies. B12 should be administered in sublingual, intranasal or intramuscular forms given that oral B12 is not absorbed due the anatomical disruption of B12 and intrinsic factor binding in gastric bypass and other malabsorptive surgeries (biliopancreatic diversion/duodenal switch).
  • Iron absorption is impaired in gastric bypass and other malabsorptive surgeries due to bypass of the duodenum (the site of iron absorption). Some patients may require intravenous iron therapy.
  • Folate deficiency may occur as a result of B12 deficiency, impaired intestinal absorption, or inadequate oral intake. Folate supplementation is recommended in patients after bariatric surgery.
  • B1 deficiency can arise in the setting of inadequate oral intake, or impaired intestinal absorption and may result in Wernicke-Korsakoff syndrome. B1 is usually a component of most multivitamin preparations, but deficient individuals can be treated with intramuscular injections.
  • Vitamin D deficiency can result from decreased oral intake, and impaired absorption due to poor mixing of vitamin D with bile salts. Daily oral supplementation is recommended.

Complications

  • Medical: Electrolyte abnormalities
  • Dumping syndrome less in BPD with duodenal switch
  • Nesidioblastosis (hyperinsulemic hypoglycemia greater than 1 hour post prandially resulting from pancreatic beta cell hyperfunction) remains controversial[6]
  • Weight regain
  • Gallstones
  • Loose skin after weight loss
  • Laparoscopic adjustable band: vomiting, pain, dysphagia, reflux
  • Surgical: Roux-en-Y gastric bypass or BPD: anastamotic leak, marginal ulceration, stomal stenosis
  • Laparoscopic adjustable band or sleeve gastrectomy: band malfunction (slippage, erosion, infection), leakage, hemorrhage, fistula

FOLLOW UP[Top]

  • Follow-up in bariatric surgery patients depends on the comorbidities and the type of surgery performed. Note, above, potential complications.
  • Diabetes recurrence can be as high as 43% after Roux-en-Y gastric bypass (associated with lower pre-operative BMI, failed weight loss, weight regain, and high post-operative blood glucose)[3].
  • Hemoglobin A1c monitoring should be continued in the post-operative period.
  • Weight loss depends on the type of operation performed. Expected average weight loss in the first 1-2 years after surgery is 45-85% and 29-87% for Roux-en-Y gastric bypass and laparoscopic adjustable band surgery, respectively.[7]

EXPERT COMMENTS[Top]

  • There is often a significant decline in post-operative requirements for insulin or oral agents due to improved insulin sensitivity post-operatively. Glucose tolerance may normalize.
  • Maintain a high index of suspicion for micronutrient deficiencies.
  • Bariatric surgery is covered by many insurance carriers (e.g. Medicaid) but specific coverage guidelines are carrier dependent.
  • Bariatric surgery enforces a new relationship to food: patients cannot eat the amount of food they previously consumed.
  • Recent findings include an increased incidence of post-operative, long-term hyperinsulinemic hypoglycemia associated with pancreatic beta cell hyperplasia (nesidioblastosis); however, these findings remain controversial.

References[Top]

  1. Centers for Disease Control and Prevention (CDC): Prevalence of overweight and obesity among adults with diagnosed diabetes--United States, 1988-1994 and 1999-2002. MMWR Morb Mortal Wkly Rep 53:1066, 2004  [PMID:15549021]

    Comment: This article reports the epidemiology of obesity in the diabetic population.

  2. Segal JB et al: Prompt reduction in use of medications for comorbid conditions after bariatric surgery. Obes Surg 19:1646, 2009  [PMID:19763709]

    Comment: Bariatric surgery can resolve type 2 diabetes.

  3. Vetter ML et al: Narrative review: effect of bariatric surgery on type 2 diabetes mellitus. Ann Intern Med 150:94, 2009  [PMID:19153412]

    Comment: This systematic review reports the effect of bariatric surgery on T2DM.

  4. Christou NV: Impact of obesity and bariatric surgery on survival. World J Surg 33:2022, 2009  [PMID:19440652]

    Comment: Bariatric surgery reduces the relative risk of death in morbidly obese patients.

  5. NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med 115:956, 1991  [PMID:1952493]

    Comment: NIH consensus panel recommendations that bariatric surgery be considered for carefully selected, morbidly obese patients with acceptable operative risks.

  6. Service GJ et al: Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med 353:249, 2005  [PMID:16034010]

    Comment: Nesidioblastosis is an uncommon phenomenon in bariatric surgery patients associated with hyperinsulinemic hypoglycemia.

  7. Buchwald H et al: Bariatric surgery: a systematic review and meta-analysis. JAMA 292:1724, 2004  [PMID:15479938]

    Comment: This systematic review reports the efficacy of bariatric surgery for weight loss.

  8. Mechanick JI et al: American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring) 17 Suppl 1:S1, 2009  [PMID:19319140]

    Comment: Guidelines published for the perioperative management of bariatric surgery patients.

  9. Dixon JB et al: Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA 299:316, 2008  [PMID:18212316]

    Comment: Laparoscopic adjustable band surgery is superior to conventional diabetes therapy for the remission of diabetes and weight loss.

  10. Adams TD et al: Long-term mortality after gastric bypass surgery. N Engl J Med 357:753, 2007  [PMID:17715409]

    Comment: Mortality is decreased after gastric bypass surgery.

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