June 26, 2017
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Duodenal switch confers better metabolic improvement vs. sleeve gastrectomy in type 2 diabetes

Adults with obesity and type 2 diabetes who underwent duodenal switch surgery saw a greater improvement in postprandial glucose excursion and beta-cell function in the 3 days after the procedure compared with those who underwent sleeve gastrectomy, according to published findings.

“Substantial improvement in glucose metabolism has been observed after bariatric surgery, but the degree of glycemic improvement varies depending on the type of procedure,” Andre C. Carpentier, MD, of the department of medicine at the University of Sherbrooke in Quebec, Canada, and colleagues wrote. “We designed the present study to compare the short-term effect of [sleeve gastrectomy] and [duodenal switch] in order to test the hypothesis that exclusion of the upper gastrointestinal tract would confer greater metabolic improvement in patients with [type 2 diabetes] undergoing bariatric surgery, independent of weight loss.”

Carpentier and colleagues analyzed data from patients with obesity recruited through the elective surgery schedule of the Quebec Heart and Lung Institute. Nine patients with type 2 diabetes and nine patients with normal glucose tolerance underwent sleeve gastrectomy; nine patients with type 2 diabetes underwent duodenal switch (mean age, 43 years; mean BMI before surgery, 46.5 kg/m²). Approximately 1 month before and on days 3 and 4 after surgery, all patients consumed a standardized meal with 295 kcal, 57 g carbohydrates, 10 g protein and 4 g lipids, to be consumed over 30 minutes. Blood samples were collected 30 minutes before and at the start of the meal, and again at 30, 60, 90, 120, 150 and 180 minutes after start of meal. Researchers measured plasma glucose, HbA1c, plasma insulin, C-peptide, leptin, pancreatic polypeptide, glucose-dependent insulinotropic peptide, tumor necrosis factor-alpha, plasma total ghrelin and total protein tyrosine and GLP-1. Researchers also measured homeostatic model of insulin resistance, Matsuda index to measure insulin sensitivity from test meals, insulin secretion rate and insulin secretion index.

Three days after surgery, patients who underwent duodenal switch had a lower fasting plasma glucose vs. those who underwent sleeve gastrectomy (P < .05); glucose concentrations were also lower for duodenal switch patients 30, 60 and 90 minutes after the meal test vs. sleeve gastrectomy patients (P < .05 for all time points).

“More importantly, the plasma glucose level increase usually observed after the meal was completely blunted in participants who underwent [duodenal switch] (P for interaction < .0001),” the researchers wrote.

Researchers also observed an increase in GLP-1 response to the meal test that was higher in patients who underwent duodenal switch vs. sleeve gastrectomy (P < .05 at 90 and 120 minutes after meal test). Total ghrelin levels remained higher in the duodenal switch group vs. the sleeve gastrectomy group (P for all time points < .01). There was also no postprandial elevation of glucose-dependent insulinotropic peptide or pancreatic polypeptide in the 3 days after duodenal switch, in contrast to what researchers observed in sleeve gastrectomy patients (P < .0001 for both).

“Our results demonstrate significant improvement in hepatic insulin sensitivity and [beta]-cell function 3 days after [sleeve gastrectomy] and [duodenal switch], suggesting a major role of sustained food restriction in the early antidiabetic effect of bariatric surgery procedures,” the researchers wrote. “We also demonstrated the superiority of [duodenal switch] over [sleeve gastrectomy] in terms of improvement in postprandial insulin sensitivity and beta-cell function 3 days after surgery, which could be explained by delayed intestinal glucose absorption and/or metabolism and/or increased postprandial GLP-1 excursion. Thus, exclusion of the duodenum and proximal jejunum provides additional metabolic benefits to caloric restriction early after [duodenal switch].” – by Regina Schaffer

Disclosures: The researchers report no relevant financial disclosures.