Posted on 05/05/2008 10:41:51 PM PDT by 2ndDivisionVet
Growing evidence shows that surgery may effectively cure Type 2 diabetes — an approach that not only may change the way the disease is treated, but that introduces a new way of thinking about diabetes.
A new article — published in a special supplement to the February issue of Diabetes Care by a leading expert in the emerging field of diabetes surgery — points to the small bowel as the possible site of critical mechanisms for the development of diabetes.
The study's author, Dr. Francesco Rubino of NewYork-Presbyterian Hospital/Weill Cornell Medical Center, presents scientific evidence on the mechanisms of diabetes control after surgery. Clinical studies have shown that procedures that simply restrict the stomach's size (i.e., gastric banding) improve diabetes only by inducing massive weight loss. By studying diabetes in animals, Dr. Rubino was the first to provide scientific evidence that gastrointestinal bypass operations involving rerouting the gastrointestinal tract (i.e., gastric bypass) can cause diabetes remission independently of any weight loss, and even in subjects that are not obese.
"By answering the question of how diabetes surgery works, we may be answering the question of how diabetes itself works," says Dr. Rubino, who is a professor in the Department of Surgery at Weill Cornell Medical College and chief of gastrointestinal metabolic surgery at NewYork-Presbyterian/Weill Cornell.
Dr. Rubino's prior research has shown that the primary mechanisms by which gastrointestinal bypass procedures control diabetes specifically rely on the bypass of the upper small intestine — the duodenum and jejunum. This is a key finding that may point to the origins of diabetes.
"When we bypass the duodenum and jejunum, we are bypassing what may be the source of the problem," says Dr. Rubino, who is heading up NewYork-Presbyterian/Weill Cornell's Diabetes Surgery Center.
In fact, it has become increasingly evident that the gastrointestinal tract plays an important role in energy regulation, and that many gut hormones are involved in the regulation of sugar metabolism. "It should not surprise anyone that surgically altering the bowel's anatomy affects the mechanisms that regulate blood sugar levels, eventually influencing diabetes," Dr. Rubino says.
While other gastrointestinal operations may cure diabetes as an effect of changes that improve blood sugar levels, Dr. Rubino's research findings in animals show that procedures based on a bypass of the upper intestine may work instead by reversing abnormalities of blood glucose regulation.
In fact, bypass of the upper small intestine does not improve the ability of the body to regulate blood sugar levels. "When performed in subjects who are not diabetic, the bypass of the upper intestine may even impair the mechanisms that regulate blood levels of glucose," says Dr. Rubino. In striking contrast, when nutrients' passage is diverted from the upper intestine of diabetic patients, diabetes resolves.
This, he explains, implies that the upper intestine of diabetic patients may be the site where an abnormal signal is produced, causing, or at least favoring, the development of the disease.
How exactly the upper intestine is dysfunctional remains to be seen. Dr. Rubino proposes an original explanation known in the scientific community as the "anti-incretin theory."
Incretins are gastrointestinal hormones, produced in response to the transit of nutrients, that boost insulin production. Because an excess of insulin can determine hypoglycemia (extremely low levels of blood sugar) — a life-threatening condition — Dr. Rubino speculates that the body has a counter-regulatory mechanism (or "anti-incretin" mechanism), activated by the same passage of nutrients through the upper intestine. The latter mechanism would act to decrease both the secretion and the action of insulin.
"In healthy patients, a correct balance between incretin and anti-incretin factors maintains normal excursions of sugar levels in the bloodstream," he explains. "In some individuals, the duodenum and jejunum may be producing too much of this anti-incretin, thereby reducing insulin secretion and blocking the action of insulin, ultimately resulting in Type 2 diabetes."
Indeed, in Type 2 diabetes, cells are resistant to the action of insulin ("insulin resistance"), while the pancreas is unable to produce enough insulin to overcome the resistance.
After gastrointestinal bypass procedures, the exclusion of the upper small intestine from the transit of nutrients may offset the abnormal production of anti-incretin, thereby resulting in remission of diabetes.
In order to better understand these mechanisms, and help make the potential benefits of diabetes surgery more widely available, Dr. Rubino calls for prioritizing research in diabetes surgery. "Further research on the exact molecular mechanisms of diabetes, surgical control of diabetes and the role played by the bowel in the disease may bring us closer to the cause of diabetes."
Today, most patients with diabetes are not offered a surgical option, and bariatric surgery is recommended only for those with severe obesity (a body mass index, or BMI, of greater than 35kg).
"It has become clear, however, that BMI cut-offs can no longer be used to determine who is an ideal candidate for surgical treatment of diabetes," says Dr. Rubino.
"There is, in fact, growing evidence that diabetes surgery can be effective even for patients who are only slightly obese or just overweight. Clinical trials in this field are therefore a priority as they allow us to compare diabetes surgery to other treatment options in the attempt to understand when the benefits of surgery outweigh its risks. Clinical guidelines for diabetes surgery will certainly be different from those for bariatric surgery, and should not be based only on BMI levels," he notes.
"The lesson we have learned with diabetes surgery is that diabetes is not always a chronic and relentless disease, where the only possible treatment goal is just the control of hyperglycemia and minimization of the risk of complications. Gastrointestinal surgery offers the possibility of complete disease remission. This is a major shift in the way we consider treatment goals for diabetes. It is unprecedented in the history of the disease," adds Dr. Rubino.
Type 2 diabetes, which accounts for 90 to 95 percent of all cases of diabetes, is a growing epidemic that afflicts more than 200 million people worldwide.
At a time when diabetes is growing epidemically worldwide, Dr. Rubino says that finding new treatment strategies is a race against time. "At this point, missing the opportunity that surgery offers is not an option."
In addition to having performed landmark studies in the field of diabetes surgery, Dr. Rubino was the principal organizer of an influential Diabetes Surgery Summit, held in Rome in March 2007. This international consensus conference helped establish the field, making international recommendations for the use of surgery and creating an International Diabetes Surgery Task Force. Dr. Rubino serves as a founding member.
Tag for later reading...
There will be a cure for type two diabetes in the next 20-30 years.
Translation: "It has become clear I can make much more money doing this surgery on more than just the obese."
Surgery is not the best answer to diabetes, or even one that will work long term. Exercise and diet are the best answers.
I'm sure someone said that 20-30 years ago.
I can cure athlete's foot by cutting off your feet, but there is a sollution outside of surgery.
Now, if we could only cure illiteracy.
How can you say that? Long term outcome with management is about the same as ignoring it, from what I have read.
>”The dudodenum is where the majority of absorbtion of nutirents takes place”< ——
Really, what’s the other 20 odd feet there for? My understanding of its function is a little more like this:
The duodenum is largely responsible for the breakdown of food in the small intestine. Brunner’s glands, which secrete mucus, are found in the duodenum. The duodenum wall is composed of a very thin layer of cells that form the muscularis mucosae.
The duodenum also regulates the rate of emptying of the stomach via hormonal pathways. Secretin and cholecystokinin are released from cells in the duodenal epithelium in response to acidic and fatty stimuli present there when the pyloris opens and releases gastric chyme into the duodenum for further digestion. These cause the liver and gall bladder to release bile, and the pancreas to release bicarbonate and digestive enzymes such as trypsin, lipase and amylase into the duodenum as they are needed.
...and if you travel faster than 20mph all the air will be forced from the vehicle and you will suffocate. Its scientific fact (or was).
BTTT
Judging by your screen name, perhaps you “Swallowed” something.
I’ve noticed how people tend to stress on the main functions of body organs, while ignoring minute, hitherto-unknown ones. Doctors are ready to lop off parts of the intestine, looking at them as if they are some sort of plumbing inside the body, and just that.
For long, they said the appendix was a useless vestigal organ, until it was found recently that it provides a reserve for probiotic agents.
The Reasoning of Fools:
If I don't know the purpose of a thing, it must not have one.
If I don't know the answer, it must be unknowable.
If I can't do it, it must be impossible.
All of the scientific theories we believe today are correct.
My Dad had a variation of this surgery. Actually, he had a bile duct bypass done 40 years ago for a choledochal cyst, by a competent surgeon at Mayo.
A few years ago, a new surgeon convinced him that they could "further reduce his risk of cancer with this great new surgery." At the time of this surgery, he was perfectly healthy; his problems from childhood with the cysts had been cured for years...but the surgeon terrified him with the prospect that he might be at risk for cancer. They performed a roux en y hepaticojejunostomy.
He nearly immediately developed diabetes (he did not have it prior to the surgery) as mentioned in the paragraph above...that theory appears to be correct.
Several years later, he developed adenocarcinoma of the bile ducts in his liver; and died three months after diagnosis.
I'm just saying: you had better have a VERY extreme case of Type II Diabetes, that has demonstrated itself completely uncontrollable with the normal treatment, before this type of drastic measure is recommended for a patient. The infection rate is rather high, I believe. I know that my Dad had back-up into his liver after surgery, and ended up spending three weeks in the hospital with a liver abscess.
The surgery itself is brutal...even when performed on a healthy person. I realize it is not exactly the same situation or procedure...but for goodness sake...it seems like total overkill; with a bunch of unknown future risks.
I do find it interesting that they may have found some "cause" in that area of the body for diabetes. Perhaps they can devise a less invasive treatment.
family friend had a daughter die from gastric bypass few months ago
Zing for later
I can cure athlete’s foot by cutting off your feet, but there is a sollution outside of surgery.
I’ll take the non-surgical approach for my headache please.
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.