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Duodenal-Jejunal Bypass for the Treatment of Type 2 Diabetes
Abstract & Commentary
By Namir Katkhouda, MD, FACS, Professor of Surgery, Chief, Minimally Invasive Surgery, University of Southern California (USC)-Los Angeles, CA. Dr. Katkhouda is a consultant for Baxter, Ethicon, Storz, and Gore.
Synopsis: Type 2 diabetes disappeared in the absence of weight loss. This goes clearly against the theory that weight loss through calorie restriction following bypass surgery for morbid obesity is the essential mechanism.
Source: Cohen RV, et al. Duodenal-jejunal bypass for the treatment of type 2 diabetes in patients with body mass index of 22-34 kg/m2: A report of 2 cases. Surg Obes Relat Dis. 2007;3:195-197.
Type 2 diabetes (T2D) affects millions of patients worldwide, with an estimated 333 million patients expected in 2025. It can be prevented and/or cured by bariatric surgery in morbidly obese patients. The clinical resolution of diabetes has been reported by Cohen and colleagues to occur in 47-70% of patients after restrictive procedures, 80-98% after Roux-en-Y gastric bypass (RYGB), and 92-100% after biliopancreatic diversion (BPD). The improvement in glycemic control after RYGB and BPD typically occurs too fast to be accounted for by weight loss alone, as postulated by Cohen et al, suggesting that these 2 operations may have a direct impact on glucose homeostasis. Both RYGB and BPD bypass the duodenum and proximal jejunum.
In 2004, Cohen et al demonstrated that duodenal-jejunal bypass (DJB), an operation that simply excludes the duodenum and proximal jejunum without restriction of the gastric volume, achieved glycemic control in nonobese rats with T2DM in the absence of weight loss or decreased caloric intake. These findings suggest that DJB might be beneficial in patients with type 2 diabetes. Consistent with this possibility are clinical observations showing that BPD can normalize plasma insulin and blood glucose levels in lean subjects with T2D, and that gastrectomies with duodenal exclusion also improve T2D in the absence of significant weight loss.
Cohen et al have performed DJB in 7 patients with T2D and a BMI of < 35 kg/m2 as part of a prospective trial. They report here the clinical history and postoperative results of the first 2 patients who were followed up for 9 months.
Methods: The inclusion criteria for surgical treatment in our prospective series were patient age of 20-30 years, BMI of 22-34 kg/m2, and a history of T2D for < 10 years; full informed consent was obtained.
The exclusion criteria were a history of T2DM of > 10 years and insulin use for > 7 years; pregnancy was excluded. IRB approval for the study on 50 patients was obtained. The operations were performed laparoscopically.
The outcome measures included hemoglobin A1c, fasting blood glucose, and plasma insulins and BMI measured one week after surgery and then monthly for the next 9 months.
Results: There were no complications, and both patients stayed 2 days in the hospital. Both patients were normoglycemic and free of their antidiabetic medication 5 weeks postop. These results were sustained at 9 months postop.
Of note, the second patient discontinued his antidiabetic medication upon discharge.
Finally, both patients who had a BMI of 29 and 27 kept the same weight at 9 months.
This is the first paper involving a duodenal-jejunal bypass in humans who are not morbidly obese. The operation was performed for control of diabetes. The results are remarkable, in that type 2 diabetes disappeared in the absence of weight loss. This clearly goes against the theory that weight loss through calorie restriction, following bypass surgery for morbid obesity, is the essential mechanism.
Cohen et al call this the foregut theory. This clinical paper confirms and opens the door for more research to determine the exact mechanism of glycemic control at the duodenal-jejunal level, and gives new hope for millions of patients that are on type 2 diabetes medications and are experiencing side effects.
One side note: Recently, a paper in the New England Journal of Medicine warned of possible serious cardiac effects of the most commonly prescribed antidiabetic medication, Avandia.