O.V. Grubnik, V.P. Golliak, V.V. Grubnik New method of Gastric Bypass for the patients with diabetes mellitus type 2 O.V. Grubnik, V.P. Golliak, V.V. Grubnik Odessa State Medical University UKRAINE

Gastric bypass (GBP) in addition to weight loss results in dramatic remission of type 2 diabetes (T2DM) M. Bose et al., Obesity surgery, 2009, № 2, 217-229. The mechanism by which this remission occurs are unclear. Besides weight loss, caloric restriction, the changes in gut hormones, that occur after GBP, are increasingly gaining recognition as key players in glucose control. Incretins are gut peptides that stimulate insulin secretion postprandial. The levels of these hormones, particularly glucagon – like peptide-1 (GLP-1) play important role in weight loss. After GBP increase of GLP-1 and decrease of glucagon levels is expected.

Proximal jejunum secrets intestinal hormones which increase a level of glucagon and increase the appetite and food intake.

The significant reduction in appetite following GBP might be secondary to hormonal modulations, because a major portion duodenum and proximal jejunum which robustly produce various gut hormones, are bypassed in this operation. Gumminys et al. (W.Ehg.J.Med., 2002, 346; 1623-30) suggested, that impairment of ghrelin secretum offer GBP might account, in part, for the loss of hunger.

GUT hormones which play an important role in appetite and weight loss GLP-1 Ghrelin GIP Mousumi BOSE1 et al. (J Diabetes. 2009 November 2; 2(1): 47–55.)

Aim of the study was to compare weight loss and satiety after standard and new method of gastric bypass

Our hypothesis: To achieve more effective weight loss and to decrease appetite and food intake we propose to remove a fundus of the stomach, which produce ghrelin, and proximal part of jejunum, which produce incretins, GIP and other intestinal hormones, which stimulate appetite and food intake

From January 2008 to December 2010 34 patients (11 male and 23 female) were operated in our clinic for morbid obesity. Mean age of the patients was 36,8+/–4,9 years Range – 29-68 years Mean BMI was 49,8+/–5,2 kg/m2, range – 43-67 kg/m2.

Type 2 DM was in 34 patients. 26 patients were categorized as severe binge eater according to the normally binge eating scale (BES).

I group - 19 patients Standard laparoscopic Roux-en-J gastric bypass was performed. A stapled jejunostomy was created 50 cm distal to ligament Treiz. A 100 cm roux limb was passed in a retrocolic and antegastric fashion. A gastrojejunostomy was created using absorbable suture in a two-layer anastomosis.

Roux-en-J gastric bypass

II group Modified gastric bypass was performed in 15 patients II group Modified gastric bypass was performed in 15 patients. New method includes resection of fundus of the stomach and resection and removing 80-100 cm of proximal jejunum.

Modified gastric bypass

Metabolic syndrome was detected in all patients Distribution of patients with standard GBP (I group) and modified GBP (II group) Standard GBP (I group) Modified GBP (II group) Number of patient 19 15 Number of patient severe binge eater 11 Number of patient (with T2DM) Mean age, (range) years 40 (29-64) 38 (30-56) Mean BMJ, kg/m2 46,5 58,6 Metabolic syndrome was detected in all patients

Data collection Preoperative fasting blood testing was done 1-3 days prior to the operative date. Postoperatively patients were kept on a liquid diet for 2 weeks, followed by a pureed diet for 2 weeks. Patients were seen in follow-up at 1, 3 and 8 weeks, and then every 3 months. Postoperative blood testing was ordered at the 3 week visit and then every 3 months.

HOMA I.R. Insulin resistance was approximated using the homeostatic model assessment for insulin resistance (Wallace et all. Diabetes Care, 2004, 27; 1487-95) The following formula was used in calculation: HOMAIR= (fasting glucose mg/dl x fasting insulin μU/ml)/ 22,5 x 18. A normal value was considered to be < 2,5.

Results There was no mortality and serious complications in both groups of the patients. After 1-2 years the mean excess weight loss was 62,8 % in I group; 89,3 % in II group (p<0,01). Mean BMI was: 36,2 kg/m2 – in I group; 29,8 kg/m2 – in II group (p<0,01).

Full resolution of T2DM was: In 10 (53%) from 19 patients in I group; In 13 (87%) from 15 patients in II group.

Median preoperative and postoperative glucose, insulin, HbAlc, and HOMOIR-levels in the patients of I and II groups. Group Glucose, mg/dl Insulin, μU/ml HbAlc, % HOMOIR-levels I group Before operation 96 15,2 5,9 3,6 After operation 89 9,8 5,6 2,1 II group 98 16,4 16,2 4,4 84 6,5 5,3 1,2

HOMA I.R. decreased significantly after both standard and modified gastric bypass. Median drop in HOMA I.R. after standard GBP was 1,4, while after modified GBP median drop in HOMA IR was 3,2 (p<0,01)

Conclusion Our preliminary results show that modified method of gastric bypass is more effective for weight loss and resolution of T2DM

Resection of part of the stomach and proximal jejunum decrease more effectively appetite and food intake in the patients then after standard gastric bypass. This study supports the hypothesis that weight loss plays an important robe in mediating intermediate clinical resolution of type 2 diabetes mellitus following gastric bypass.