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Bariatric surgery, as a whole, is the only proven modality to manage the severely obese. The laparoscopic sleeve gastrectomy (LSG) is the most recent tool in the armamentarium of bariatric surgery. Once used as the first-stage in a two-stage procedure for the super-obese patient, it is now used as a primary bariatric procedure. Involving the resection of the greater curvature of the stomach, it has been shown to achieve clinically significant excess weight loss and improvements in obesity-related co-morbidities. Its mechanism of action was originally classified as being a restrictive procedure, similar to laparoscopic gastric banding, but is now known to be far more complex. The pronounced effects of LSG on gut hormones such as ghrelin, PYY and incretins, allow this bariatric intervention to be adequately compared to the more historically classified malabsorptive procedures like the gastric bypass. In this review, we explore the metabolic effects and outcomes of LSG in producing significant weight loss and improving the factors associated with the metabolic syndrome.

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Diabetes Mellitus has been one of the most prevalent diseases in human beings from the very beginning.

Its prevalence is estimated at about 8% in different societies and with increasing body mass index of people all over the world the rate of type 2 diabetes is increasing (1).

It is estimated that about 90% of diabetic patients are of type 2 (2).

Weight loss, and the change in life style remains the cornerstone of its treatment.

Different oral and injectable drugs have been used to treat this debilitating disease, but so far even in the most developed countries like US the rate of uncontrolled diabetes mellitus is more than 20 % (3).

This rate is even higher in some countries.

Since 1955 the role of gastric surgery to improve diabetes was reported and in 1991 NIH consensus recommended bariatric surgery for diabetic patients with BMI to be more than 35 (4).

Resolution of hyperglycemia in morbid obese patients a few days after some bariatric surgeries -even before enough weight loss- showed there are other mechanisms that are responsible for such dramatic results.

Many investigations showed different hormonal roles in that effect.

Glucagon as one of the most important gut hormones which has a major role for insulin resistance is decreased promptly after gastric bypass surgery.

This finding resulted in the production of Foregut theory and at present the changing direction of food away from duodenum is essential in all diabetic surgeries.

In gastric bypass, biliopancreatic diversion, and biliopancreatic diversion–duodenal switch which have been postulated to be the most effective bariatric surgeries on resolution of diabetes mellitus type 2, this deviation of food direction is seen.

It seems that restrictive bariatric surgeries, like sleeve gastrectomy and gastric banding and vertical gastric plication have less effect on diabetes mellitus type 2 resolutions.

It may be because they mostly act by weight reduction mechanism, although hormonal effect of sleeve gastrectomy on ghrelin and reduction of gastric emptying time may have some hormonal effect.

Another major theory for resolution of diabetes mellitus type 2 after bariatric surgery is hindgut theory, which is mainly described by hormonal release from L cells by reaching undigested food to distal ileum.

These hormones are mainly GLP1, and Peptide YY.

These magical results -which resolved diabetes mellitus type 2 even in about 98% of patients- gave a new vision to scientists about bariatric surgery (5).

In this regard Metabolic and Diabetic surgery nomination was done.

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Background

Laparoscopic one anastomosis gastric bypass (OAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are common treatments for morbid obese patients who suffer from type 2 diabetes mellitus (T2DM). It has been hypothesized that diabetes may be resolved or improved after bariatric procedures, although the exact effect has not been well established. The present study aimed to compare remission of T2DM after LRYGB versus OAGB in this study.

Methods

All diabetic obese patients, aged between 16 to 60, who referred to Hazrat Rasul Akram obesity clinic from April 2010 to March 2013 for LRYGB or OAGB were included in the present study. Pre-operative parameters, including glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), body mass index (BMI), and type of diabetes medication were extracted from database and recorded. Pre-operative and three months postoperative values were then compared between the groups.

Results

Out of 95 eligible patients, 50 patients underwent OAGB and 45 patients had LRYGB. The two groups were homogenous in distribution of gender, mean age, weight, BMI, and FPG; however, mean HbA1C was relatively higher in LRYGB group (P = 0.05) than other group, which was non-significant after adjustment. Rate of remission was significantly higher in OAGB group than other group after three months follow-up (64.0 versus 31.1%, respectively) (P = 0.002).

Conclusions

In our short-term follow-up, OAGB had a higher rate of remission of T2DM compared to LRYGB, which could be due to different baseline value of HbA1c (before surgery) between two groups. Future research is thus suggested with linger follow-up and randomized study design.