It appears from all that is now known about GLP-1 that ileal transposition would be an ideal operation for treatment of type 2 DM. Release of enteroglucagon from the ileum has probably contributed to weight control in bypass operations for obesity, but the effect has been obscured by the associated malabsorption. The release of GLP-1 after meals has probably been beneficial to patients treated with gastric bypass who had type 2 DM. This is a recommendation for well-planned studies of ileal transposition in the treatment of type 2 DM and obesity. Ileal transposition is not recommended for general use until such studies have shown safety, efficacy, and the requirements for patient selection.
This case illustrates not only the importance of informed consent in patients undergoing obesity operations, but also the importance of adequate follow-up for patients who have undergone these procedures. A thorough history and physical examination, a high index of clinical suspicion, and careful long-term follow-up, with specific laboratory testing, are needed to detect early metabolic bone disease in these patients.
The National Bariatric Surgery Registry (NBSR) results reflect low perioperative risk for obesity surgery. Five deaths occurred within 40 d of operation in 5178 patients (0.1%). A subset of 3174 patients with complete information for complication and postoperative hospital stay was further studied. Females comprised 87% of the data set. Median values were determined for age, 37 y (18-70 y); operative weight, 121 kg (77-288 kg); and operative body mass index (BMI), 44 kg/m2 (29-91 kg/m2). Patients with no complications (89.7%) were reported to have a median postoperative stay of 4 d (2-23 d). The most severe complications were deep venous thrombosis (0.3%) and gastrointestinal leak (0.6%), with median postoperative hospital stay of 12 d (ranges 2-27 and 4-59 d, respectively). The most frequent complication reported was respiratory (4.5%), with median postoperative stay of 6 d (3-34 d). Median postoperative hospital stay for wound infection (1.6%) was 5 d.
Gastric bypass is an extensive gastric exclusion operation used in patients who are more than twice their ideal weight. Most of the early postoperative deaths observed in 3% of 442 patients during the initial 9 years, could have been prevented by more attention to operative technique and early recognition and correction of leaks when they occurred. The best weight loss can be produced by adherence to three components of the operation: 1) Bypass of stomach and duodenum, 2) a small fundic segment and 3) a small (12 mm diameter) gastroenterostomy stoma. The average patient of 142 kg can expect to have a weight of around 107 kg at 1 year 103 kg at 5 years. Revision of a large stoma to a smaller (9 mm) diameter can induce further weight loss in some patients whose loss has been inadequate. The 1.8% incidence of stoma ulceration may be lowered with the present emphasis on a smaller fundic pouch, but could increase with longer observation. Presently stoma ulcers occur once in every 140 patient years at risk.
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