The Comparison Of Effect Of Sleeve Gastrectomy And Roux-En-Y Gastric Bypass On Morbidly Obese Patients With Diabetes Mellitus

BACKGROUNDBariatric surgery is a rapidly evolving branch of surgical science.The aim is to induce major weight loss in those whose obesity places them at high risk of serious health problems.Shanghai Changhai Hospital put forward new concept of bariatric surgery in CHINA:focus on the treatment of obesity related disease.The amount of diabetes mellitus in China is over 50 millions,90%of it is type 2 diabetes.Obesity is so closely associated with typeⅡdiabetes that a causal role for obesity-or very closely related factors-is beyond doubt.In the morbidly obese,the relative risk of type 2 diabetes is at least 5%in men and 8-20%in women,while approximately 30%of those considered for bariatric surgery are found to have type 2 diabetes.In the surgical arm of the Swedish Obese Subjects(SOS) study the prevalence of diabetes was 10.8%at baseline and remained 10.5%8 years after surgery.In contrast,however,the prevalence of diabetes in the control group increased from 7.8%to 24.9%over the same period.In the Greenville series an additional 13%of patients had impaired glucose tolerance(IGT) pre-operatively, confirming that without intervention many severely obese patients are at high risk of progressing to diabetes.In subjects with IGT,bariatric surgery also has a powerful preventive effect on progression to diabetes.Recently reports show Bariatric surgery is associated with a high rate of resolution of type 2 diabetes mellitus(T2DM) in morbidly obese subjects.Sleeve Gastrectomy,a restrictive operation,has been more and more popular in western country.There is limited data evaluating the impact of Sleeve Gastrectomy on the control of diabetes mellitus.Let alone the data on the comparison of effect of Sleeve Gastrectomy(SG) and Roux-en-y Gastric Bypass(RYGB) on morbidly obese patients with diabetes mellitus.OBJECTIVEEvaluate the effectiveness of Sleeve Gastrectomy and Roux-en-y Gastric Bypass In improving glycemic control of morbidly obese patients with diabetes mellitus.Discuss the mechanism of both surgery on diabetes mellitus.Research the diabetes-specific endpoints.METHODThe study was approved by the Hospital Ethics Committee and written informed consent was obtained from all participants,we conducted a prospective collected database of all 60 patients with diabetes mellitus,who underwent LSG and LRYGB as a final approach for the treatment of morbid obesity and who have completed at least 6 months of follow-up postoperatively at the Bariatric Institute at Cleveland Clinic Florida between April 2007 and January 2008.30 patients with diabetes mellitus randomly selected to be underwent laparoscopic sleeve gastrectomy(LSG) and 30 patients with diabetes mellitus randomly selected to be underwent laparoscopic Roux-en-y gastric bypass(LRYGB) were studied. Data collected included demographics,weight loss(BMI,EWL%),diabetes control(FPG,HbA1C) and Ghrelin.Summary statistics,including mean and standard deviation were calculated for all numeric variables.Categorical variables were summarized by N and percentage.Fisher's exact tests were used to examine the relationship between two categorical variables,such as dichotomized duration of disease and disease resolution.Average preoperative and postoperative biochemical markers for the study group were calculated and analysed by Student's t-test,and the average change in these markers within each operation group compared by Repeated Measurement Data Analysis Of Variance.Statistical analyses were carried out using SPSS 11.5 software(SPSS Inc.,Chicago,IL,USA).Statistical significance was set at a P value＜0.05.RESULTFor the RNYGB group BMI(Kg/M~2) dropped from 46.37±3.47 preoperatively to 37.70±2.26 at 2 months and 33.30±1.75 at 6 months after surgery.For the SG group BMI(Kg/M~2) dropped from 46.83±4.97 preoperatively to 37.87±4.61 at 2 months and 34.13±3.92 at 6 months after surgery.From baseline to six months there was no significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes BMI (F=0.288,P=0.594).For the RNYGB group FPG(mg/dl) dropped from 150.37±11.76 preoperatively to 111.60±15.86 at 2 months and 98.70±11.92 at 6 months after surgery.For the SG group FPG(mg/dl) dropped from 149.60±15.63 preoperatively to 128.13±19.10 at 2 months and 112.03±15.51 at 6 months after surgery.From baseline to six months there was significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes FPG (F=8.145,P=0.006),RYGB is better than SG.For the RNYGB group HbA1C(%) dropped from 7.19±0.63 preoperatively to 6.09±0.74 at 2 months and 5.51±0.26 at 6 months after surgery.For the SG group HbA1C(%) dropped from 7.18±0.81 preoperatively to 6.38±0.55 at 2 months and 5.81±0.37 at 6 months after surgery.From baseline to six months there was significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes HbA1C(F=4.753, P=0.033),RYGB is better than SG.In SG group patients with the shorter duration of diabetes(＜5years) and better weight loss after surgery achieved higher resolution rates (X~2=8.623,P=0.005).There was no significant difference between groups RYGB P=0.054.Patients with the shorter duration of diabetes(＜5years) achieved lower HbA1C postoperative.In RYGB group T=5.854,P=0.000 at 2 months and T=3.531,P=0.001 at 6 months,respectively,T=6.390,P=0.000和T=4.984,P=0.000 in SG group.Patients with the result of resolution on diabetes mellitus had better weight loss than improvement.In RYGB group T=5.755,P=0.000 at 2 months and T=7.081,P=0.010 at 6 months,respectively,T=22.438,P=0.000和T=11.231,P=0.000 in SG group.In RYGB group ghrelin levels decreased during 3 day postoperative and then gradually increased,and rose further at 6 months.In SG group ghrelin levels kept stable decrease during 6 months postoperative.CONCLUSIONSThis study suggests that weight loss surgery(RYGB and Sleeve Gastrectomy) are equally effective in promoting weight loss,but the RYGB is more effective in controlling glycemia.Patients with the shorter duration of diabetes(＜5years) and better weight loss after surgery achieved higher resolution rates of diabetes mellitus.Ghrelin may play major role on the procedure of SG on treatment of diabetes mellitus.Better effect of RYGB indicates the changes of gastroenteritic-insular axis may play major role on the surgical treatment of diabetes mellitus.