Predicting Remission of Type-2 Diabetes With Ileal Interposition With Sleeve Gastrectomy

Surendra Ugale, MS, Neeraj Gupta, MBBS, Vishwas Naik, MS, Kd Modi, MD, Sunil Kota. Kirloskar Hospital and Medwin Hospitals, Hyderabad, Andhra Pradesh, India

Aim- Combination of Laparoscopic Ileal Interposition with sleeve gastrectomy offers good metabolic improvement and weight reduction without causing significant malabsorption.
In a country with more than 62 million diabetics, India can soften the impact of rising healthcare costs in an environment of good economic growth, if resources are focused on selected group of patients, with impending complications of nephropathy, retinopathy or cardiac disease, by using factors predicting successful outcomes after Ileal Interposition
Methods- The II&SG was performed in 43 patients (M:F=26:17) from January 2008. Participants had mean age of 47.53± 8.82 years (range 29-64 years), mean duration of diabetes 9.75± 8.82 years (range- 1 to 32 years) and mean preoperative BMI 32.05 ± 7.5 kg/mt2. All patients had poorly controlled type 2 diabetes mellitus (mean HbA1C- 9.57 ± 2 %) despite use of oral hypoglycemic agents (OHA) and/or Insulin. Thirty (70%) patients had hypertension, 19 (44%) had dyslipidemia and 19 (44%) had significant microalbuminuria.
Results- Mean follow up was 11.3 ± 9 months (range: 1-32 months). Postoperatively glycemic parameters (FBS, PLBS, HbA1C) improved in all patients (p<0.05) at all intervals. Eighteen patients (45%) had remission in diabetes and the remaining patients showed significant reduction in AHA dosage. significantly decreased OHA requirement. All patients had weight loss between 15%-30% (p<0.05). Twenty seven patients (90%) had remission in hypertension. At 2 years mean fall in HbA1C (36%) was more than reduction in BMI(20%). There was a declining trend in lipids and microalbuminuria postoperatively.
Remission of diabetes and Hypertension and metabolic improvement was clearly more in patients with BMI > 27 kg/mt2 , duration of diabetes ≤ 10 years and stimulated C-peptide > 4 ng/ml.
Conclusions- Laparoscopic Ileal Interposition with sleeve gastrectomy, based on the principle of neuroendocrine brake, appears to be safe and a potentially effective option for remission of type 2 diabetes. Hypertension is a major risk factor for cardiovascular disease and micro vascular complications such as retinopathy and nephropathy. Seventy five percent of our patients (30/43) had hypertension. In majority of them i.e. 27/30 (90%) hypertension subsided after surgery Patients with shorter duration of diabetes, higher BMI and higher stimulated C-peptide values would respond better, enabling a focused utilization of scarce resources, to prevent major complications like nephropathy, retinopathy & cardiac events, to avoid the large financial drain on the country’s economy