Surendra Ugale, MD. Kirloskar Hospital & Asian Bariatrics
Background: Compliance with medical management of “Diabesity” is poor, leading to the gradual deterioration of pancreatic B cell function, increased requirement of medications and eventual complications.
An evolving procedure, Laparoscopic ileal interposition (II) with a BMI-adjusted sleeve gastrectomy (SG), offers good control of type-2 diabetes and other metabolic derangements and also helps in weight reduction without causing significant malabsorption. There are two versions of this procedure, jejunal (nondiverted) and duodenal (diverted) ileal interposition. It is effective in controlling T2DM not only in obese but also in non obese.
Methods: The II & SG was performed at two hospitals, as a multicenter study, in 490 patients from February 2008 to December 2013. Patients had mean age of 43.5 years, mean duration of diabetes was 9.5 years and mean preoperative body mass index (BMI) of 29.5 kg/m2.
2/3rds of the patients had BMI less than 35. All patients had poorly controlled type 2 diabetes mellitus (mean HbA1c- 9.8%), despite use of oral hypoglycemic agents (OHA) and/or insulin. 64% patients had hypertension, 60% had dyslipidemia and 45% had significant microalbuminuria. The primary outcome was remission of diabetes (HbA1c less than 6.0% without OHAs/insulin) and secondary outcomes were changes in components of metabolic syndrome.
Results: With a mean follow up of 24 months (range between 10 and 72 months), postoperative glycemic parameters, (fasting blood sugar (FBS), post lunch blood sugar (PLBS) and HbA1c) improved in all patients at all intervals. Hospital stay was between four and six days; operative duration ranged between 240 and 360 minutes. 72% had complete remission of diabetes (HbA1c less than 6 without any medication); 81.5% had partial remission. Mean weight loss was 23.5% (18 to 28 %). Resolution of hypertension was seen in 92.5% (blood pressure less than 130/80 mmHg), dyslipidemia in 89.5% and microalbuminuria in 80%.
At two years mean fall in HbA1c (26.5%) was more than the reduction in BMI (21%; range between 15 and 25%). The main post operative problems were food intolerance, seen in 12%; diarrhea and abdominal pain seen in 4%. Total complication rate was 7.75 % (38 out of 490 patients) and mortality rate from procedure was 0.2 %.
Conclusions: This multicenter study suggests that laparoscopic ileal interposition with sleeve gastrectomy is a promising procedure for control of type 2 diabetes, hypertension, obesity and associated metabolic abnormalities, especially with a low recurrence rate and minimal nutritional concerns.