Can A Gastric Bypass Procedure Have A Positive Impact On Diabetes?

By Chad Friedman, DPM, and Doug Pacaccio, DPM

   The Roux en-Y procedure begins with creating a small pouch at the top of the stomach. The pouch is used to restrict the food intake. The surgeon would make the pouch by utilizing parallel surgical staples that divide the stomach into two parts. The smaller upper portion of the stomach will serve as the new stomach whereas the remaining portion of the stomach is intact so it can make its normal secretions into the duodenum.

   The next step involves cutting a portion of the small intestine (bypassing the duodenum and the first portion of the jejunum) and connecting this to the small pouch of the stomach (the Roux Limb). This causes reduced calorie and nutrient absorption.8

   The Roux limb allows food to pass directly from the small pouch of the stomach into the new connection, bypassing the remaining portion of the stomach, duodenum and the first part of the jejunum. The final step involves reconnecting the unused portion of the stomach and small intestine to the Roux limb with staples. This “y-connection” allows food to mix with pancreatic fluid and bile, aiding the absorption of important vitamins and minerals.9 The surgeon can alter the length of either segment of the intestine to produce lower or higher levels of malabsorption.10

Educating Patients On The Potential Pros And Cons

   When considering the possibility of referring a patient for this procedure, it is important that patients are aware of the possible risks.

   Granted, with any surgery, there are always risks and possible side effects. However, bypassing of the duodenum interferes with iron and calcium absorption.3 This can lead to anemia as well as osteoporosis. Other risks include infection, gastritis, ulcers, vitamin B12 deficiency, loosening of the staples, hernia and dumping syndrome. Dumping syndrome occurs when there is a rapid emptying of the stomach contents into the small intestine.10 This happens when the patient has too much sugar or food. This can lead to nausea, vomiting, diarrhea, bloating, dizziness and sweating. Stomal stenosis may also occur. This involves a narrowing of the connection between the stomach and small intestine.

   Yet studies have shown positive benefits of this procedure. A recent article from The American Journal of Surgery retrospectively looked at open Roux en-Y gastric bypass in 925 patients without mortality.11 The results from the study showed hypertension resolved in 70 percent of patients and diabetes mellitus resolved in 58 percent of patients. The series outperformed the national averages with excess weight losses of 40 percent at three months, 78 percent at 12 months and 84 percent at 18 months.11

   Another study showed the effects of laparoscopic Roux-en-Y gastric bypass on patients with type 2 diabetes four years after the procedure. Fasting plasma glucose and glycosylated hemoglobin concentrations returned to normal levels (83 percent) or markedly improved (17 percent) in all patients.12 A significant reduction in the use of oral antidiabetic agents (80 percent) and insulin (79 percent) followed surgical treatment.12 Patients with the shortest duration (12

   Not only does gastric bypass help to resolve issues of type 2 diabetes but the procedure has also shown to improve diabetic neuropathy, hypertension, hypercholesterolemia and obstructive sleep apnea.

In Conclusion

   Given the promise of these studies and the potential benefit to patients who are obese and diabetic, podiatrists may want to consider referring patients for this procedure. As noted above, one should facilitate appropriate multidisciplinary consults and ensure that these patients have a strong understanding of the potential benefits and risks of the procedure.

Dr. Friedman is a third-year resident at the Washington Hospital Center in Washington, D.C.

Dr. Pacaccio is a third-year resident at Inova Health System in Fairfax, Va.

Dr. Steinberg (pictured) is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C.

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