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

By Chad Friedman, DPM, and Doug Pacaccio, DPM

How The Gastric Bypass Procedure Has Evolved Over The Years

   At the end of the 1800s and early 1900s, surgeons performed bypass on patients with peptic ulcers and also utilized the procedure as a treatment for stomach cancer. Obesity surgery began in 1954 at the University of Minnesota with the empiric use of intestinal bypass.3,5 Complications of intestinal bypass led to overgrowth of bacteria in the bypassed area of the bowel, kidney stone formation and cirrhosis. In 1966, researchers introduced gastric bypass at the University of Iowa with the belief that this surgery would restrict the intake of food without creating the complications of malabsorption that surgeons had observed with intestinal bypass.3    Today, the most frequent gastric bypass operation in the U.S. is the Roux en-Y gastric bypass, which Giffen introduced in 1977.3,5 Alkaline gastritis from early gastric bypass led to the Roux en-Y reconstruction. Other gastric bypass or bariatric bypass procedures are the vertical banded gastroplasty, the biliopancreatic diversion and the Lap-Band. Over the last decade, the popularity of gastric bypass has greatly increased since Wittgrove and Clark introduced laparoscopic techniques in 1994.3,7    The Roux en-Y procedure is a combination of a restrictive and a malabsorptive procedure. The malabsorptive aspect decreases the amount of calories absorbed and accordingly leads to weight loss while the restrictive aspect reduces the size of the stomach. Current restrictive procedures provide a very limited gastric reservoir that fills rapidly, leading to early satiety.3    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

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