sign in sign up
<<
Home , Proglucagon, Resistin

Surg Endosc DOI 10.1007/s00464-008-0168-6

Hormonal evaluation following laparoscopic treatment of mellitus patients with BMI 20–34

Aureo Ludovico DePaula Æ A. L. V. Macedo Æ V. Schraibman Æ B. R. Mota Æ S. Vencio

Received: 19 April 2008 / Accepted: 2 September 2008 Ó Springer Science+Business Media, LLC 2008

Abstract (GLP-1), glucose-dependent insulinotropic (GIP), Background A group of patients with type 2 diabetes , , C-peptide, , colecystokinin mellitus (T2DM) and body mass index (BMI) 20–34 kg/m2 (CCK), (PPP), , peptide were submitted to laparoscopic interposition of a segment YY (PYY), , , , , and inter- of into the proximal jejunum or into the proximal leukin-6 (IL-6). associated to a sleeve gastrectomy. The objec- Results Thirty patients had II associated to sleeve gas- tive of this study is to evaluate the hormonal changes in the trectomy (II-SG) and 28 had II with diverted sleeve pre- and postoperative period. gastrectomy (II-DSG). GLP1 exhibited an important rise Materials and methods Hormonal evaluation was done in following the two operations, especially after II-DSG 58 patients operated between April 2005 and July 2006. (p \ 0.001). GIP also exhibited an important rise, with both Mean age was 51.4 years (40–66 years). Mean BMI was II-SG and II-DSG being equally effective (p \ 0.001). 28.2 (20–34.8) kg/m2. All patients had had the diagnosis of Insulin and amylin showed a significant rise at 30 min. T2DM for at least 3 years. Mean duration of T2DM was Glucagon decreased slightly. CCK measurements were very 9.6 years (3–22 years). Two techniques were performed, low after II-DSG. PPP was also slightly altered by the II- consisting of different combinations of ileal interposition DSG. PYY showed an important increase with both oper- (II) associated to a sleeve gastrectomy (SG). The following ations (p \ 0.001). Ghrelin showed a significant decrease were assayed in the pre- and postoperative period following the two operations (p \ 0.001).Somatostatin and (mean 16 months) at the baseline and following specific IL-6 were not affected (p = 0.632). Both leptin and resistin food stimulation (30, 60, 120 min): glucogen-like 1 blood levels decreased. Adiponectin showed a slight increase. Mean postoperative follow-up was 19.2 months. Both II-SG and II-DSG were effective in achieving ade- A. L. DePaula quate glycemic control (91.2%). Gastrointestinal Surgery, Hospital de Especialidades, Conclusions There was a significant hormonal change Goiania, Brazil following laparoscopic ileal interposition. These alterations A. L. DePaula (&) may explain the promising good results associated to these Av. 136, no. 961, 14° andar, Setor Marista, operations for the treatment of T2DM in the nonmorbidly 74.093-250 Goiania, Goias, Brazil obese population. e-mail: [email protected]

A. L. V. Macedo Á V. Schraibman Keywords Diabetes Á Gastrointestinal hormones Á Albert Einstein Hospital, Sao Paulo, Brazil Á Ileal interposition Á Neuroendocrine brake V. Schraibman e-mail: [email protected] The difference in insulin secretion between intravenous B. R. Mota Á S. Vencio Department of Surgery, Hospital de Especialidades, versus oral glucose administration is referred to as the in- Goiania, Brazil cretin effect [1]. There is evidence that most of this effect is

123 Surg Endosc mediated by glucagon-like peptide-1 (GLP-1) and glucose- only are fasting plasma levels of GIP elevated, but there is dependent insulinotropic peptide (GIP) [2]. In type 2 dia- also augmented GIP secretory response to oral glucose betes mellitus (T2DM) the effect is markedly load. Relative insensitivity of gut K-cells to intestinal decreased. Reduced GLP-1 secretion is observed while GIP glucose, coupled with desensitization of the GIP receptor levels are normal or elevated [3]. The insulinotropic effect following prolonged exposure to increased GIP plasma of GIP is abolished and resistance to GIP is a characteristic levels in the impaired state, are the likely causes of dys- feature of the diabetic state, while GLP-1 action is rela- regulation of GIP secretion at this moment and tively well preserved [4]. dysregulation of action seen in T2DM [13]. Zhou et al. Gastrointestinal hormones affect glucose in [14] demonstrated that GIP plays a crucial role in switching synchrony with the central nervous system at different from oxidation to fat accumulation under diminished levels: by altering food intake and body weight (insulin insulin action and inhibition of GIP signaling ameliorated sensitivity); by affecting gastric delay and gut motility . The second characteristic of this opera- (meal-related glucose fluctuations); affecting insulin tion is correction of the defective amplification of the late- secretion (plasma glucose levels); and by affecting tissue- phase plasma insulin response to glucose by GIP and specific insulin sensitivity of glucose metabolism [5]. amelioration of insulin resistance by diminishing (standard DePaula et al. [6] described an operation (neuroendocrine version) or abolishing (diverted version) the excessive brake, NEB) specifically for the treatment of the nonmor- stimulation of the duodenum K-cells. bidly obese T2DM clinical population with micro- and The increasing prevalence of worldwide is macrovascular . The NEB has two versions: the accompanied by an explosion in the prevalence of type 2 standard one, in which the duodenum is in continuity with the diabetes. Approximately 60% of all cases of diabetes are digestive tract, and the diverted version, in which the duo- attributable to obesity [15]. Persisting high caloric intake denum is bypassed. The NEB intends to address the current may be another detrimental factor to diabetes remission, as pathophysiological mechanisms of T2DM, involving neu- insulin sensitivity is impaired in the presence of high rohormonal mechanisms, caloric restriction, and weight loss. caloric intake [16]. In addition to its well-know role in It is suggested that IGT or T2DM patients exhibit mainly modulating metabolism, ghrelin directly regulates glucose a defective early insulin release, the insulin release seen and has been shown to suppress insulin during the initial 30 min after meal intake or oral glucose. secretion in humans [17]. The incretins effect on ghrelin The underlying cause of the defective early insulin response remains unclear. Ghrelin is produced predominantly in the is not known, and may be due to intrinsic beta-cell defects , and on isolated stomach insulin was the most or to defective augmentation by incretins [7]. Loss of early- effective inhibitor of postprandial ghrelin secretion, with phase insulin secretion has severe consequences for glucose GLP-1, , and somatostatin being potential candi- homeostasis. Insulin-sensitive tissues are not adequately dates to have the same effect [18]. The inverse relationship primed to transport glucose, glucagon secretion, free fatty- between ghrelin and insulin following carbohydrate-rich acid secretion, and hepatic glucose output are not sup- meals suggests a tight regulatory interaction. It has been pressed, resulting in continued delivery of glucose into the shown that low plasma ghrelin levels correlates with ele- circulation [8]. Rask et al. [9] demonstrated that there was vated fasting insulin levels in T2DM and that endogenous an early (30-min) reduced GLP-1 response in patients with ghrelin in islets acts on beta-cells to restrict glucose- IGT. GLP-1 is one of the products of the induced insulin release [19]. The third characteristic of this of L cells in the gut. The majority of these cells are thought operation is the resection of part of the stomach in order to to reside in lower jejunum and terminal ileum [10]. The provide long-lasting control of obesity and decrease the prehepatic insulin secretion is dose-dependent potentiated circulating levels of ghrelin. by GLP-1 and this is particularly powerful during the first The objective of this study is to evaluate the hormonal 30 min after meal ingestion. A tenfold increase in active changes following laparoscopic interposition of a segment GLP-1 levels resulted in a twofold increase in insulin of ileum to the proximal jejunum or into the proximal secretion [11]. So, the first characteristic of the neuroen- duodenum associated to a sleeve gastrectomy in order to docrine brake operation is early exposition of ingested control T2DM in patients with BMI 20–34 kg/m2. nutrients to an interposed distal ileum intending to deter- mine an early and significant rise of GLP-1 in order to correct the defective early (first-phase) insulin secretion. Materials and methods The pathophysiology of T2DM also involves a defective amplification of the late-phase (20–120 min) insulin Hormonal evaluation was performed in 58 patients with response to glucose by GIP, regardless of etiology and T2DM operated between April 2005 and July 2006. Mean phenotype [12]. In subjects with IGT but not diabetes, not age was 51.4 ± 7.3 years (range 40–66 years). Mean BMI

123