Sleeve Gastrectomy

and Type 2 Diabetes

Jin S. Yoo M.D.

Assistant Professor of Surgery

Duke University Medical Center

Jin.Yoo@duke.edu

Financial Disclosures

• Covidien (consultant / speaker)

• Cook Medical (consultant / speaker)

• Musculoskeletal Tissue Foundation (consultant)

• W.L. Gore (consultant / speaker)

Personal Disclosure

• I also agree that RYGB is the best operation for

morbidly obese patients who wishes to have the

best chance for T2DM resolution.

• However… not everyone can (or will) want the

RYGB for many valid reasons…

• So, I would like to focus on how SG is not a bad

“second choice” for T2DM.

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Mechanism(s) by which SG improves T2DM

• Weight loss (restoration of insulin sensitivity)

- physical restriction

- ↓ ghrelin ↓ appetite

• Accelerated gastric emptying and neuro-hormonal

mechanisms

- ↑ GLP-1 ↑ beta-cell mass ↑ insulin production1

- ↑ PYY-1 ↑ beta-cell mass ↑ insulin production2

- Enhanced nutrient stimulation of neuroendocrine L cells of the

distal small bowel3

Page 4 1 Cummings DE et al. N Engl J Med 2005; 353: 300-2.

2 Karamanakos SN et al. Ann Surg 2008; 247: 401-7.

3 Francesco R et al. Annu Rev Med 2010; 61: 393-411.

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NO SIGNIFICANT DIFFERENCE:

- % EWL

- % T2DM remission

- ↑GLP-1 (in response to meal)

75% had remission ≥ 12 mos

Risk factor for failure of remission:

Longer duration of T2DM

Higher pre-op Hgb A1c level

Pre-op insulin requirement

Lower EWL

12% had recurrence

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T2DM

resolution:

-RYGB 93%

-SG 47%

But,

-BMI < 35

- Taiwanese

So SLEEVE GASTRECTOMY

may be inferior to ROUX-EN-Y

GASTRIC BYPASS in terms of

T2DM resolution and % EWL

(but not by much).

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• Randomized, nonblinded, single-center trial

• Intensive medical therapy vs medical therapy plus surgery (RYGB or SG)

• BMI 30-40 in uncontrolled T2DM patients

• 1-yr follow-up

• Surgery group superior to intensive medical therapy group

• No difference between in SG and RYGB

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• 18 patients

• 9 underwent SG and 9 underwent medical therapy

• 1 year follow-up

• T2DM resolution in 8/9 pts in SG group (NONE in medical group)

• Patient who did not resolve had T2DM for 20 years and was also on

85 units insulin/d pre-op Page 10

Page 11

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So SLEEVE GASTRECTOMY is

also significantly better than

medical therapy in T2DM

patients with BMI < 35.

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Predictors of successful remission of

T2DM with SG

• T2DM duration < 10 years1-4

• Pre-op C-peptide level > 3 ng/mL4

• Minimal or no insulin-dependence pre-op?

• BMI < 45? (so the final BMI will be in the normal

range)

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1 Schauer PR et al. Ann Surg 2003; 238: 467-84.

2 Ponce J et al. Obes Surg 2004; 14: 1335-42.

3 Rosenthal R et al. SOARD 2009; 5: 429-34.

4 Abbatini F et al. SOARD 2012; 8: 20-24.

4 Lee WJ et al. Surgery 2010; 147: 664-9.

Summary

• SG is a suitable alternative to RYGB for the

treatment of T2DM (even in patients BMI < 35)

• Risk factors for failure of remission or recurrence

are:

- T2DM duration > 10 years

- pre-op insulin dependence

- higher pre-op Hgb A1c level

- lower pre-op C-peptide level

- suboptimal weight loss and/or weight regain

- advanced age

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