The purpose of this research is to confirm that laparoscopic Sleeve Gastrectomy (LSG) can be used to controltype 2 diabetes in obese patients with the optimumnutritional support that is based on adequate protein intake to assurehealthy safe weight loss. Thegoal for treating type 2 diabetes is to improve the symptoms and to preventlong-term complications such as neuropathy, nephropathy, retinopathy and other microand macro-complications. This goal is achieved by strict continuouscontrol of blood glucose levels via weight loss, diet, exercise, and medications.
When both dietary and medical therapyfails to control diabetes, bariatric surgeryconsidered for its sustained weight loss and improvement in the quality of life. LSG offers a great opportunity for majorweight loss for people with obesity (with BMIof 30 associated with other co-morbidities) and super-obese patients (with BMImore than 60) or simply those who failedother methods to lose their weight.According to the American Association for Metabolicand Bariatric surgery, ASMBS (2017) it has been found that: Individualswho underwent bariatric surgery showed significant improvement in theirdiabetic status. Bariatric surgeries performed in more than 135,000 patientswere found to affect type 2 diabetes with the following mechanisms:Ø Surgeryimproves type 2 diabetes in nearly 90 percent of patients by:· Achieving low blood sugar levels· Reducing both the dosage and typeof medication used to treat diabetes (oral or injections) · Better improvement in mostdiabetes-related health complications Ø Surgerycauses type 2 diabetes to go into remission in 78 percent of individuals by:· Achieving better reduction inblood glucose levels to normoglycemia · Decrease or eliminate the need for diabetic medications · Eliminate the need for diabetesmedicationsØ HealthImprovements· Longer remission or improvementof T2DM for years Also, ASMBS (2017) has found the following:Sleeve gastrostomy appears to have satisfyingoutcomes of weight-loss-independenteffects on glucose metabolism and also causes somechanges in gut hormones that favor improvement in diabetes. The percentage ofdiabetes mellitus remission is considered high and significant after LSG (60%and more) that is resembling the results after gastricbypass. 1.0 Defining termsA clear and completedefinition of the focal terms mentioned in this proposal is essential.
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Asstated by Mahan and Raymond, 2017 Diabetes Mellitus – (DM) “is defined by agroup of diseases characterized by high blood glucose concentrations resultingfrom defects in insulin secretion, insulin action, or both. Type 2 Diabetes – (T2DM)characterized by a combination of insulinresistance and beta-cell failure”. Laparoscopic Sleeve Gastrectomy – (LSG) –often called the sleeve – “is performed by removing approximately 80 percent ofthe stomach. The remaining stomach is a tubular pouch that resembles a bananathat is narrow and provides a much smaller reservoir for food” (ASMBS, 2017). For the monitoring of diabetes control according to theAmerican Diabetic Association, ADA (2017): “1- Glycosylated Hemoglobin – (HbA1cor A1C) is a blood test that gives a picture of the average blood glucose(blood sugar) control for the past 2 to 3 months. The result gives a good ideaof how well diabetes treatment plan is workingand Fasting Plasma Glucose – (FPG) is a blood test that checks fasting bloodglucose levels”.
2.0 Justification of the ResearchAs it is stated by ASMBS, (2017):”In 2011, a multidisciplinary team of specialists’, e.g.
, diabetologists, endocrinologists,surgeons and public health experts gathered at the 2nd. World Congress on Interventional Therapies for Type 2 Diabetesin New York City. According to the supporting evidencepresented by these experts, The International Diabetes Foundation (IDF)released a Position Statement asking for the early consideration of bariatricsurgery as a treatment of T2DM. In summarizing of the released document fromthe IDF:· Alongwith the behavioral and medical treatments, bariatric surgeries present aprimary opportunity to improve the control of diabetes for patients sufferingfrom obesity. · Therisk of mortality and complications after bariatric surgery is considered lowand resemble other well-acceptedprocedure such as gallbladder surgery.· Bariatricsurgery is considered a proper treatment for people suffering from obesity andT2DM, and not able to reach their target goals with their medical treatments.· Patientsof a BMI 30-35 with poor control of T2DM on optimum medical interventions, along with major cardiovascular risk factors, mustbe considered for bariatric surgery as another line of therapy. · Treatmentof T2DM by bariatric surgery is cost-effective.
· Individualswith T2DM and a BMI of 35 or more, surgery must be an acceptable choice forthem.Bariatricsurgery for patients suffering from T2DM should be implemented within clear guidelines that include a multidisciplinary plan of careapproach constitute from medical experts, follow-upsand clinical audit, proper patient, andfamily education to be given andexplained well, along with an efficient surgicalpractice. Based on the above statement, this proposal is aiming to confirm andsupport the use of laparoscopic sleeve gastrectomy to control T2DM with propernutritional intervention. 3.0 Research MethodologyRichdeep et al.(2010) conducted a systematic review ofall studies reported from 2000 to April 2010. In his review, it is suggested thatin obese patients, a failure might occur of beta-cells in the pancreas tosecrete adequate levels of insulin –due to the excess body fat – to compensatefor the insulin resistance in peripheral tissues, which ultimately leads totype 2 DM.
The possible mechanism of action in the weight loss post-LSG is believed to be secondary to the restriction of food intake by the small gastricreservoir. Currently, the theory of hormonal changes has been postulated to be involved as well. It has been found in thereviewed studies, a marked reduction of fasting ghrelin levels after LSGsurgery. Ghrelin is a hormone produced primarily by the gastric fundus, whichinhibits insulin secretion and blocks hepatic insulin signaling. It was stated that by reducing ghrelin levelsand its “insulinostatic effect,” theislet cells of the pancreas will be probably able to secrete additional insulinby increasing the maximal capacity of glucose-induced insulin release. (Richdeepet al.
2010).”This systematic review study revealed that there are 27studies and673 patients were analyzed. The baseline mean body mass index for the 673patients was 47.4 kg/m2 (range 31.0 –53.5). The mean percentage of excessweight loss was 47.
3% (range 6.3–74.6%), with a mean follow-up of 13.
1 months(range 3–36). DM had resolved in 66.2% of the patients, improved in 26.
9%, andremained stable at 13.1%. The mean decreasesin blood glucose and hemoglobin A1C after sleeve gastrectomy was _88.2 mg/dLand _1.7%, respectively” (Richdeep et al. 2010).The types of studies which were reviewedincluded human retrospective and prospective case series.
Those studies that were considered targeted a population of adult (above18years old) male or female patients with type 2 DM who had undergone LSG. Toconsider a patient is obese are those with a BMI more than 30 kg/m2 and they were included. The focal intervention was LSGas a solitary procedure or as a first-stage procedure in all bariatricprocedure. The outcomes that were measured included both primary and secondaryoutcomes. The primary outcome was the resolutionof type 2 DM that was defined asdiscontinuation of all hypoglycemic medications and/orinsulin and normal readings of both fasting plasma glucose level as well asnormal postprandial glucose, in addition to normal hemoglobin A1c (HbA1c). Thesecondary outcomes measured the change in BMI, percentage of excess weightloss, and change in glucose levels, HbA1c levels, mortality, and postoperativecomplications. (Richdeep et al.
2010)In this proposal, the focus is mainly about the outcome of thesurgery which is established by rapid and sustained weight loss, excessive fatloss, therefore improving the diabetes control by increasing the sensitivity ofinsulin in addition to the adequate and sufficient amount of insulin levels. Such outcomes cannot be achieved easily by the onlydiet and exercise especially for morbidly obese patients who are mostly sufferingfrom limited mobility (for having arthritis, back or knee pain, etc.) or othercomorbidities that restrict, restrain and delay the weight loss, in addition tothe muscle wasting for not complying to the recommended diet program (due tothe desire of fast weight loss that is not usually achieved by most healthydiet program or due to the poor well of the patients to follow the giveninstructions).
Nutritionalintervention and support are essential duringall stages and steps of the surgery (as both pre and post op). Focusing onconsuming the required amount of protein and other needed nutrients for maintainingoptimum nutritional status during the journey of weight loss. (Richdeep et al.2010).
3.1 Supporting EvidenceBoth dietary and medical therapy for severely obese patients haslimited short-term success and almost non-existent long-term success.Therefore, surgical intervention must be considered to eliminate the increasedrisk of complications from type 2 diabetes. Bariatric surgery has been apopular tool in the war against obesity by medical personnel and patients whofailed the conventional treatment (lifestyle changes and medications).
Thomaset al. (n.d.)Weight loss surgery results in greater and sustained weight lossthan conventional treatment and leads toimprovements in quality of life and obesity-relateddiseases such as hypertension, sleep apnea, dyslipidemia, and many medicalillnesses. Thomas et al. (n.
d.)There evidencesupport LSG as a surgical option for bariatric patients to produce long-termsustainable weight loss, with the improvementof T2DM, is increasing. Richdeep et al. (2011), reviewed several studies forLSG, and stated in his article that there was an assessment of LSG in 17 obese(BMI >50) patients with T2DM and demonstratedan 80% resolution rate for T2DM. He revealed as well that a study was completed for diabetic patients who wentunder LSG, 75 high-risk morbidly obese (BMI >60) patients with T2DM. His findings werethat those patients had a percentage excess weight loss of 46% and had 81% T2DMresolution following LSG at 12 months follow-up.
He also reviewed a prospectivestudy, which included 39 patients with T2DM. These patients had a T2DMresolution rate of 81%, with a reduction of HbA1c levels from 7.4 to 6.9.
Shahand colleagues evaluated LSG in 58 obese (mean BMI 45) T2DM and found animpressive 96% resolution rate for T2DM. HbA1c levels in these patients droppedon average from 8.4% to 6.1 %.Richdeepet al.
(2010) also studied the risks of surgery such as malabsorption andinternal hernias postoperatively are which has been found to be minimal.Dumping syndrome has not been reported asa postoperative issue. “The operative mortality at 30 days was .36% for all LSG(not only DM patients) procedures (4 deaths of 1117 patients) based on 16studies. Postoperative complications such as bleeding occurred in 1.79% (20 of1117 patients). Postoperative abscess or infection occurred in .
27% (3 of 1117patients). Postoperative leaks occurred in 22 of 1117 patients (1.97%)”. Based on those early data and results, it is established in Richdeep et al.
(2010) review that laparoscopic Sleeve Gastrectomy (LSG), a less technicallycomplex procedure, is being considered as a surgical option for obese patients.According to Michell et al. (2012) “proteinintake should be quantified periodically by the medical team to ensure adequateeducation and implementation of the prescribed diet.
3.2 Arguments to Negate the FactThe first line treatment for type 2 diabetes is weight loss with diet (that is basically meant to follow a healthy meal planning) and exercise(regular exercising helps burning excess calories, managing weight thusimproves control of blood glucose levels). Once diet and exercise – lifestyle changes – arenot sufficient to control blood glucose, medications will be added. Mechanism of actions varies byincreasing insulin secretion, and/or byimproving the sensitivity of insulin or decreasing the absorption ofcarbohydrates from the gastrointestinal tractor decreasing glucose production from the liver. In patients with poor controlof diabetes despite lifestyle changes and medications, insulin must be includedin the treatment. Surgical intervention for controlling diabetes is consideredsecondary to the conventional treatments after lifestyle changes andmedications.
Thomas et al. (n.d.)Onthe other hand, the American Society for Nutrition, ASN (n.d.) has released abreakthrough:In 2002, the Diabetes Prevention Program (DPP),funded by the National Institute of Diabetes and Digestive and Kidney Diseases(NIDDK), showed that an intensive lifestyle intervention that included medicalnutrition therapy, weight loss of 5-7 percent, and exercise was more effectivein preventing the progression from pre-diabetes to diabetes than was drug therapyalone.
During the study, the chance of developing diabetes was 58 percentlower in the lifestyle intervention group, but only 31 percent lower in thegroup receiving drug therapy.