Endocrine Abstracts

Objective: Laparoscopic ileal interposition (II) with sleeve gastrectomy (SG)/diverted sleeve gastrectomy (DSG) are types of modified bariatric surgery for treatment of type 2 diabetes (T2DM). DSG is preferred over SG in patients with less favourable metabolic profile. Owing to variable remission response in our patients, retrospectively we devised a novel score metabolic surgery assessment score (MSAS). It helps to select the type of procedure and to predict the diabetes remission before surgery.

Methods: Forty-six patients underwent II+SG and 29 for II+DS II+DSG was performed on 29 patients. MSAS was calculated based on preoperative parameters. MSAS of the subjects with and without remission (maintaining HbA1c <6.5% without any medication) were compared.

Results: Patients subjected to II+SG had mean age of 48.3±8.1 years, duration of T2DM 9.8±7.6 years and body mass index (BMI) 32.1±6.9 kg/m². All patients had poorly controlled diabetes with HbA1C 9.5±2.2%. Mean MSAS in patients who underwent II + SG (n=46) was 9.2±1.4. Twenty one (46%) had remission in diabetes. In the same group, patients with BMI ≥35 kg/m², MSAS was 8.9±1.7 and remission rate was 85%. MSAS was significantly lower in patients with remission than patients without remission (8.1±0.8 vs 10.2±0.9, P<0.0001).

Patients subjected to II+DSG had mean age of 48.7±7.8 years, duration of T2DM 13.1±5.8 years and BMI 29.1±6.7 kg/m². All patients had poorly controlled diabetes with HbA1C 9.8±1.8%. Mean MSAS in patients who underwent II + DSG (n=29) was 10.4±1.3 (significantly higher than II+SG group, P=0.0004). Twenty one (72%) had remission in diabetes. MSAS was significantly lower in patients with remission than patients without remission (9.7±0.8 vs 12.0±0.5, P<0.0001).

Patients with MSAS ≥10 in II+SG group and MSAS ≥12 in II+DSG group did not get remission. MSAS was not significantly different (P=0.1468) in patients without remission in II+SG (10.2±0.9) vs patients with remission in II+DSG (9.7±0.8). This indirectly suggests that DSG instead of SG would have helped them in achieving remission.

Discussion: The surgery addresses the foregut and hindgut mechanisms leading to remission in T2DM. The SG component restricts calorie intake and induces ghrelin (orexin) loss.II leads to rapid stimulation of interposed ileal segment by ingested food leads resulting in augmented GLP-1 secretion. DSG leads to better remission by exclusion of Rubino’s factor and GIP from duodenum, abolition of hedonic effect of food, earlier stimulation of ileum leading to better incretin response.

Conclusion: Preoperative MSAS can be a useful tool to select the type of surgical procedure and to predict post operative diabetes remission.