The Efficacy of Mini-Gastric Bypass Surgery in Diabetic and Prediabetic Obese Patients

Abstract

Background:

Our aim was to investigate the efficacy of mini-gastric bypass (MGB) surgery in diabetic and prediabetic obese patients.

Materials and Methods:

Sixty-five patients who had MGB operation and met the study criteria were examined. Patients with a body mass index (BMI) of ≥35 were divided into groups based on age, gender, BMI, bypass length, and cardiological risk groups.

Results:

The study included a total of 65 patients (45 women and 20 men). There was no difference between the cardiac risks and bypass lengths of women and men. We found a statistically significant decrease in the postoperative 3- and 12-month A1c levels of the class II and class III obese women and men compared with the preoperative values. When the postoperative 3- and 12-month A1c levels were compared, there was no significant difference in the A1c levels of the class II obese patients, whereas there was a significant decrease in the A1c levels of the class III obese patients according to the regression analysis (p < 0.05).

Conclusion:

Our results seem to be supportive of the MGB as an effective treatment strategy for diabetes remission and prediabetic cases.

Introduction

Obesity is a result of the complex interaction of genetic, nutritional, and metabolic factors. It plays a significant pathophysiological role in the development of health problems.¹ According to the World Health Organization data, it is estimated that ∼2 billion of adult people are overweight, and of these 650 million are obese.² The increasing prevalence of obesity forms a basis for the development of diabetes mellitus, hypertension, cardiovascular diseases, cancer, stroke, and several metabolic disorders.³

The frequency of use of bariatric surgery has increased since it produces more effective results than nonsurgical treatments in long-term continuous weight loss and improvement of metabolic disorders.⁴ Recently, the second Diabetes Surgery Summit (DSS-II), an international consensus conference, has developed a general guideline suggesting the inclusion of bariatric/metabolic surgery in glucose-lowering treatments for selected patients with type 2 diabetes and obesity.⁵

It has been reported that bariatric surgery has beneficial effects on mortality, disease-specific risk reduction, and long-term quality of life in type 2 diabetes.⁶ In recent years, a surgical technique, known as mini-gastric bypass (MGB) with single anastomosis, fewer complications, and similar long-term results with Roux-En-Y gastric bypass, has been developed and become a commonly used procedure in the treatment of both obesity and type 2 diabetes.⁷

A1c is a reliable indicator used in the evaluation of long-term glycemic control in diabetic patients, although it does not give an idea about changes in plasma glucose levels and does not reflect hypoglycemic attacks.⁸ The American Diabetes Association (ADA) recommends studying A1c tests two times a year for type 2 diabetes patients with good metabolic control, and three times a year for all diabetic patients with poor glycemic and metabolic profile.⁹

Owing to the rapid increase in the prevalence of obesity and type 2 diabetes worldwide, the use of surgical treatment techniques to reduce these diseases is increasing.¹⁰ There are many studies and literature data regarding different bariatric/metabolic surgical techniques. Studies and data on MGB surgery, which is one of the bariatric/metabolic surgical techniques, are limited. In our study, we aimed to investigate the effects of the type of bariatric/metabolic surgery on glycemic control in obese type-2 diabetic patients who underwent MGB operation.

Materials and Methods

Among 676 patients who underwent bariatric surgery, our study was conducted on 65 out of 78 patients who had MGB operation and met the study criteria. The data of this study were obtained from diabetic patients who were operated with the MGB technique for blood sugar regulation and obesity treatment between January 2016 and January 2019. The data of the patients were retrospectively obtained from the patient files. Ethical approval numbered 6306/1 and dated September 27, 2019 has been obtained from the Academic Ethics Committee of Private Medicana International Samsun Hospital.

The study cohort consisted of adults (>18 years) with a body mass index (BMI) of ≥35 kg/m² who underwent bariatric/metabolic surgery and who were followed by our endocrinology and bariatric surgery clinic. Those with primary endocrine/systemic disease, any inflammatory disease, celiac disease and malabsorption, inflammatory gastrointestinal disease, and cancer patients were excluded from the study. In line with the objectives of this study, the baseline and postmetabolic surgery 3- and 12-month biochemical data were evaluated.

Operative technique

In this technique, the esophagogastric junction is first dissected and released from the left and right diaphragmatic crura. The dissection is then advanced up to the insertion of the latarjet nerve on the right. Afterward, the small curvature is vertically and horizontally cut with a stapler and a narrow pouch with a length of 15–18 cm and a capacity of 50–150 mL is created. The stapler lines are continuously sutured with 3–0 polydioxanone and reinforced. The gastric pouch created and the jejunum are anastomosed with the help of an endostapler 200 cm distally to the ligament of Treitz, and the staple space is closed up with 3/0 polydioxanone suture (Fig. 1).

FIG. 1.

Schematic representation of mini-gastric bypass surgery.

Statistical analysis

The SPSS 25.0 (IBM Corporation, Armonk, NY) and PAST3¹¹ software were used in the analysis of variables. The normality of univariate data was evaluated with the Lilliefors-corrected Kolmogorov–Smirnov test and the variance homogeneity was evaluated with the Levene test, whereas the normality of multivariate data was evaluated with Mardia's (Dornik and Hansen omnibus) test and the variance homogeneity was evaluated with the Box-M test. In the comparison of two independent groups according to quantitative data, the independent samples t-test was used with bootstrap results, whereas the Mann–Whitney U test was used with the Monte Carlo simulation technique. Friedman's two-way test was used to compare more than two repeated measures of dependent quantitative variables, whereas Dunn's test was used for post hoc analyses. The quantitative variables were expressed as mean ± standard deviation (minimum to maximum) and median ± interquartile range, whereas the categorical variables were shown as n (%) in the tables. The variables were analyzed at a confidence level of 95%, and a p-value of <0.05 was considered significant.

Results

A total of 65 patients (45 women and 20 men) were included in this study. The mean age of the female patients was 52 ± 10 (range 24–68) years, whereas the mean age of the male patients was 43.4 ± 9.5 (range 23–62) years. When the ages of the female and male patients were compared, the mean age of the female patients was statistically significantly higher (p < 0.001). When the BMI of the female patients (48.4 ± 8) and the BMI of the male patients (42.7 ± 6.8) were compared, the BMI of the female patients was statistically significantly higher (p < 0.014). There was no difference between the cardiac risks of the male and female patients. There was no difference between the intestinal bypass lengths of the female and male patients. Of the patients, 12 had a BMI of ≥35 and 53 had a BMI of ≥40. The demographic data of the patients included in the study are shown in Table 1.

Table 1.

Demographic Characteristics of Diabetic Obese Patients Who Underwent Mini-Gastric Bypass Operation

	Diabetes mellitus demography (yes)		p
	Female (n = 45)	Male (n = 20)	p
Age, mean ± SD			0.001
BMI, median ± IQR			0.014
CVS, n (%)
Low	17 (37.8)	9 (47.4)	0.580^fe
Moderate	28 (62.2)	10 (52.6)
High_excluded	0	1
Bypass length, median ± IQR	200 ± 0	200 ± 20	0.108^a

The bold values indicate statistical differences of the relevant parameters.

Mann–Whitney U test (Monte Carlo).

Fisher Freeman Halton Test (Monte Carlo).

BMI, body mass index; CVS, cardiovascular system; IQR, interquartile range; SD, standard deviation.

According to the glycemic control evaluations of the diabetic obese patients who underwent MGB operation, there was a statistically significant difference between the preoperative and postoperative 3- and 12-month A1c values of the female and male patients in the intragroup comparisons; moreover, there was a significant decrease in the A1c levels according the regression analysis of the preoperative and the postoperative 3- and 12-month HbA1c levels, as is seen in Table 2.

Table 2.

Change in A1c of Diabetic Obese Patients Who Underwent Mini-Gastric Bypass by Gender

	Diabetes mellitus demography (yes)		p-Value for intragroup^a
	Female (n = 45)	Male (n = 20)	p-Value for intragroup^a
	Median ± IQR	Median ± IQR
HbA1c
Baseline (A)	7.2 ± 3.9	6.1 ± 2.7	0.367
3 Months (B)	6 ± 2	5.1 ± 0.8	0.296
12 Months (C)	5 ± 1	4.1 ± 1	0.191
Change
(B − A)	−1.2 ± 2.9	−1 ± 2	0.675
(C − A)	−2.2 ± 3	−2 ± 2.1	0.588
(C − B)	−1 ± 1	−1 ± 1.2	0.888
p-Value for intragroup^b	<0.001	<0.001
Pairwise comparison
A → B	<0.001	0.013
A → C	<0.001	<0.001
B → C	<0.001	0.013

The bold values indicate statistical differences of the relevant parameters.

Mann–Whitney U test (Monte Carlo).

Friedman test (Monte Carlo); post hoc test: Dunn's test.

According to the glycemic control evaluations of the diabetic obese patients who underwent MGB operation based on obesity classes, there was a statistically significant decrease between the preoperative and postoperative 3- and 12-month A1c levels when the obese and morbidly obese patients were compared (p < 0.001). In addition, there was a significant decrease between the preoperative A1c levels and the postoperative 3- and 12-month data of the obese patients (p < 0.05). In the morbidly obese patients, there was a significant decrease between the preoperative and the postoperative 3- and 12-month A1c levels, as well as between the postoperative 3- and 12-month A1c levels, as is seen in Table 3 (p < 0.001). Of the 65 diabetic patients included in the study, 12 (18.4%) were obese and 53 (81.5%) were morbidly obese.

Table 3.

Change in A1c by Obesity Class

	Obesity class		p-Value for intragroup^a
	II (n = 12)	III (n = 53)
	Median ± IQR	Median ± IQR
HbA1c
Baseline (A)	6.03 ± 3.94	7.19 ± 3.9	0.446
3 Months (B)	5.05 ± 1	5.82 ± 1.03	0.208
12 Months (C)	5 ± 0.93	5 ± 0.96	0.443
Change
(B − A)	−1 ± 3.08	−1.07 ± 2.62	0.864
(C − A)	−1.06 ± 3.13	−2.02 ± 2.95	0.694
(C − B)	−0.96 ± 1.04	−1 ± 1	0.468
p-Value for intragroup^b	<0.001	<0.001
Pairwise comparison
A → B	0.033	<0.001
A → C	<0.001	<0.001
B → C	0.070	<0.001

The bold values indicate statistical differences of the relevant parameters.

Mann–Whitney U test (Monte Carlo).

Friedman test (Monte Carlo); post hoc test: Dunn's test.

Discussion

Both in the United States¹² and globally, the prevalence of type 2 diabetes has increased dramatically for the past decade. These data show a very significant increase in the prevalence of diabetic obesity. Apart from nutrition and pharmacological treatments, bariatric/metabolic surgery has recently been used as the preferred treatment in diabetic obesity patients. The efficacy of these surgical procedures in weight control has been extensively described in studies. Moreover, one of the most important effects of bariatric/metabolic surgery is the remission of diabetes. In our study, the MGB technique provided blood sugar regulation in obese diabetics. In the follow-ups, the cases were found to be in complete remission.

Obesity is a very important risk factor for the development of type 2 diabetes. Especially the fact that 90% of type 2 diabetes patients are obese is an indicator of this. Studies have reported that individuals with a high BMI are at higher risk of developing type 2 diabetes, and that the risk of type 2 diabetes decreases as body weight decreases.^13,14 In our study, the development of diabetes in obese prediabetics is also prevented by the MGB technique.

The rapid increase in the prevalence of morbid obesity and diabetes has increased the demand for effective surgical treatment modalities performed to correct this condition.^10,12–15 The efficacy and complications of bariatric operations for the treatment of obesity bring about the search for new surgical techniques. The MGB technique, which was first described by Rutledge in 2001, has now been successfully used to treat obesity in many different countries worldwide.¹⁶ The publication of studies supporting the ease of use of the MGB technique and the fact that it causes less mortality and morbidity due to its single anastomosis encourages surgeons to perform this operation. In our study, no complication or mortality occurred in the cases. The MGB technique has been shown to be an effective surgical technique in improving metabolic disorders associated with obesity, glycemic control, reducing drug use, improving lipid levels, increasing the quality of life, and permanent weight loss.¹⁷ In our study, we found that 45 female patients achieved blood sugar regulation and that type 2 diabetes was in complete remission. The other 20 male patients were prediabetic cases, and the development of diabetes was prevented in these patients and the blood sugar and A1c values were normalized.

Wang et al. reported that the MGB technique had the advantages of less anastomosis, preserved intestinal continuity, easy antecolic anastomosis, and a larger gastric pouch for future operative return.¹⁸ Rutledge et al. have confirmed that it is a simpler and effective procedure in addition to showing a similar effect with that of the Roux-en-Y gastric bypass technique in terms of reducing morbidities that accompany obesity and long-term metabolic complications in morbidly obese patients undergoing MGB surgery.¹⁹ In our study, the MGB technique was used in all cases, and we found that blood sugar regulation, remission rates were complete and prediabetic patients were prevented from progressing to diabetes. Morbid obesity shortens the lifespan of patients between 5 and 15 years.²⁰ According to the 2018 data of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), the rate of women has been reported to be significantly higher than that of men among patients undergoing bariatric surgery. In the same study, it was stated that 92.3% of the male population were in the metabolically unhealthy group.²¹ In our study, we calculated the BMI of the female patients as 48.4 ± 8 and the BMI of male patients as 42.7 ± 6.8. We found that our results are in parallel with the literature data. In our study, of the cases, 81.5% consisted of class III and 18.4% consisted of class II obese patients. In 2011, the ADA and the World Health Organization reported that A1c levels should be followed up both for the diagnosis of diabetes mellitus and as the glycemic control criteria, and those with an A1c level of 6.5% should be evaluated as diabetic.²² In recent years, A1c measurements constitute an important part of the clinical treatment approaches for patients with diabetes mellitus (DM).²³ Recent studies have shown that patients with long-term weight loss >5% have a positive effect on DM, A1c, and blood pressure.²⁴ A recent study reported that the HbA1c levels of patients were <7%, <6.5%, and <6% when patients with DM but a BMI of <30 kg/m² were systematically followed up after bariatric surgery.²⁵ According to the ADA, remission of patients with DM has been defined as a return to normal A1c levels and glucose metabolism measurements without pharmacological treatment or ongoing medical procedures for at least 1 year.²⁶ In line with the ADA data, the levels of A1c in our study returned to normal levels at a 1-year time interval after the operation. At the same time, we found that the postoperative A1c levels of these patients were statistically significant when the male and female patients were evaluated among themselves. In studies, the remission criteria were based on parameters such as A1c, insulin, and weight loss.²⁷ It has been reported in many studies that A1c is <6.5%, weight loss is 55% in type 2 diabetes remission, whereas some studies have reported an A1c level of ≤6.^28,29 Although there are different data in the literature, complete remission rates have been shown to be 90% in 3-year data.³⁰ In our study, we found that all patients had complete remission in the 1-year data compared with the literature, and that the A1c level was 5% ± 1% in type 2 diabetic patients and 4.1% ± 1% in prediabetic patients. In class II and class III obese patients, we showed a significant decrease in the 3- and 12-month A1c levels compared with the preoperative A1c level. We demonstrated that MGB surgery was effective in diabetic obese patients.

In general, the MGB technique reveals its potential efficacy in achieving diabetes remission. Although the Roux-en-Y gastric bypass technique remains the gold standard for diabetes remission, the MGB technique can become a valuable alternative, as it may have similar diabetes remission mechanisms and the procedure is easier to perform. Although our results seem to be supportive of the MGB as an effective treatment strategy for diabetes remission and prediabetic cases, there is a need for more studies to draw conclusions about the ideal procedure to achieve diabetes remission.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding information

No funding was received for this article.

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