Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass.
The global prevalence of type 2 diabetes mellitus and impaired glucose metabolism continues to rise in conjunction with the pandemic of obesity. The metabolic Roux-en-Y gastric bypass operation offers the successful resolution of diabetes in addition to sustained weight loss and excellent long-term outcomes in morbidly obese individuals. The procedure consists of the physiological BRAVE effects: (i) Bile flow alteration; (ii) Reduction of gastric size; (iii) Anatomical gut rearrangement and altered flow of nutrients; (iv) Vagal manipulation and (v) Enteric gut hormone modulation. This operation provides anti-diabetic effects through decreasing insulin resistance and increasing the efficiency of insulin secretion. These metabolic outcomes are achieved through weight-independent and weight-dependent mechanisms. These include the foregut, midgut and hindgut mechanisms, decreased inflammation, fat, adipokine and bile metabolism, metabolic modulation, shifts in gut microbial composition and intestinal gluconeogenesis. In a small minority of patients, gastric bypass results in hyperinsulinaemic hypoglycaemia that may lead to nesidioblastosis (pancreatic beta-cell hypertrophy with islet hyperplasia). Elucidating the precise metabolic mechanisms of diabetes resolution and hyperinsulinaemia after surgery can lead to improved operations and disease-specific procedures including 'diabetes surgery'. It can also improve our understanding of diabetes pathogenesis that may provide novel strategies for the management of metabolic syndrome and impaired glucose metabolism.
Ashrafian
H
H
The Department of Surgery and Cancer, Imperial College London, London, UK. h.ashrafian@imperial.ac.uk
Athanasiou
T
T
Li
J V
JV
Bueter
M
M
Ahmed
K
K
Nagpal
K
K
Holmes
E
E
Darzi
A
A
Bloom
S R
SR
D001786:Blood Glucose / Q000378:metabolism; D003924:Diabetes Mellitus, Type 2 / Q000378:metabolism / Q000601:surgery; D015390:Gastric Bypass; D006801:Humans; D006946:Hyperinsulinism / Q000378:metabolism / Q000601:surgery; D007328:Insulin / Q000097:blood / Q000378:metabolism; D024821:Metabolic Syndrome / Q000378:metabolism / Q000601:surgery*; D009767:Obesity, Morbid / Q000378:metabolism* / Q000601:surgery*
D001786:Blood Glucose; D007328:Insulin