Метаболитна Хирургия срещу интензивно медикаментозно лечение на диабет тип 2 - 5 годишен резултат

Метаболитна Хирургия срещу интензивно медикаментозно лечение на диабет тип 2  - 5 годишен резултат

Хирургичното лечение на Захарен Диабет тип 2 не е мит, а реалност. За съжаление инвазията на лекари извън Европейския съюз и масираната реклама на илеалната транспозиция за лечение на диабет тип 2 при пациенти с Индекс на тегло под 30 налага да се даде малко повече информацив по този въпрос.

Ivaylo Tzvetkov, Dimitar Tzankov,                                                                                                   Chesterfield Royal Hospital, UK                                                                                                     Hospital “Sveta Marina”, Pleven, Bulgaria 
Aim of the study
The aim of the study is to reveal initial experience with Surgical Treatment of Type 2 Diabetes in patients with BMI over 35 kg/m. We tried to compare the effect of the main types of  metabolitic procedures:                                                                                                                                                     - restrictive as vertical gastroplasty by Champion technique and Sleeve gastrectomy                       - malabsortive procedures as Gastric by pass on Diabetes type II in those patients and influence of surgery over  the metabolic control of diabetes and its associated risk factors.   
Matherial and Methods
Selection of patients was done to following criteria:                                                                                        - BMI over 35kg/m                                                                                                                                - moderate or well controlled Diabetes type 2 with oral or on insulin therapy                                      - controlled co-morbidity as arterial hypertension, sleep apnea, reflux disease                                  - lack of alcohol abuse or severe mental disorders                                                                              - contraindications for general anesthesia. 
Thirty six patients with Diabetes type 2 and Morbid Obesity were included in the study. Preoperative assessment included:                                                                                                                    - blood sugar control before surgery,  and the same control on 1st and 3rd week after surgery.                                                                                                                                                              -  follow up of blood sugar 3,6 and 12 months after Metabolic Surgery                                                 - preoperative assessment of HbA1c and insulin levels 2 weeks before surgery. Their values  were followed up 6 to 48 months after surgery.  
Thirty four patients did not need any medical treatment about Diabetes type 2 within 15 to 18 months after surgery. The other two patients were only on oral therapy and diet for treatment of Diabetes type 2. The blood pressure was normal in 27 patients 6 months after surgery. The other 9 patients reduced oral intake of medications for that co-morbidity significantly (p> 0,05). About 14 patients had improvement of arterial blood supply of lower limbs 4 to 6 months after metabolic surgery done by Doppler duplex scan. The quality of life in all patients was assessed by themselves with 8 to 10 points according to VAS 6 months to 1 year after surgery.

Diabetes type 2 remits or improves in the majority of patients after bariatric surgery. The procedures producing greater excess weight loss as Gastric bypass and Sleeve Gastrectomy lead to higher remission rates.                                                                                                                     We need a Bulgarian official survey and agreement between surgeons and endocrinology specialists to establish national guidelines for treatment of Morbid obese patients with Diabetes type 2. The societies of Bulgarian surgeons and endocrinology specialists have to make further steps to inform the society and Ministry of Health that surgical treatment of Diabetes type 2 is not a myth or an experiment with commercial issues, but a medical based evidence for a new treatment option of Diabetes type 2 all over the world.

Ivaylo Tzvetkov
Chesterfield Royal Hospital, UK
Aim of the review
Type 2 diabetes, which accounts for 90–95% of all cases of diabetes, is a growing epidemic that places a severe burden on health care systems, especially in developing countries. 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.
Methods of review
Engine search options were Medline and Cohrain data Library. The review included key words as: Surgical management of Diabetes type 2, intestinal transposition, metabolic surgery. About 235 articles and publications were checked, investigated and certain data selected for further investigation and retrieval. Meta analysis was used to select criteria and data for assessment. Laparoscopic sleeve gastrectomy with ileal transposition was investigated as an option for surgical management of Diabetes type 2.
A meta-analysis selected 78 studies for a total of  12456 patients  and it 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. Some of those studies showed that complete remission of diabetes occured in 48% of patients after laparoscopic gastric banding, 84% after RYGB, and >95% after BPD. Illeal transposition with sleeve gastrectomy showed postoperatively that glycemic parameters (fasting and post-lunch blood sugar, HbA1C improved in all patients (P < 0.05) at all intervals. At least (47%) patients had remission in diabetes and the remaining patients showed significantly decreased OHA requirement. All patients had weight loss between 15 and 30% (P < 0.05). Most of patients (90%) had remission in hypertension. At 3 years, the mean fall in HbA1C (34%) was more than reduction in BMI (25%). There was a declining trend in lipids and microalbuminuria postoperatively, though it was significant for microalbuminuria only. So, all procedures as RYGB, BPD and illeal transposition seemed to be even more effective in diabetes than in obesity itself. This findings suggested that the aim of bariatric operations should address surgical procedures that result in more than just weight loss. 
Most of the bariatric procedures improved significantly Diabetes type 2. The novel laparoscopic Ileal transposition with SG seems to be a promising procedure for control of type 2 DM, hypertension, weight reduction, and associated metabolic abnormalities in patients with BMI more than 30. Multicenter studies with larger number of patients and a longer follow-up period is needed.  The main questuion is about safety and relaibility of the procedure in patients with BMI <30 and results about that are still contorversial and studies are experimental. There are no medical based evidences, published in Europe about support of ileal transposition for patients with BMI < 30.