Obesity plays a key role in the pathophysiology of type 2 diabetes (T2DM), and weight loss is a major objective, although difficult to achieve with medical treatments. Bariatric surgery has proven its efficacy in obtaining marked and sustained weight loss, and is also associated with a significant improvement in glucose control and even diabetes remission. Roux-en-Y gastric bypass appears to be more effective in diabetic patients than the restrictive gastroplasty procedure. This may be explained not only by greater weight reduction, but also by specific hormonal changes. Indeed, increased levels of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) may lead to improved β-cell function and insulin secretion as well as reduced insulin resistance associated with weight loss. The presence of T2DM in obese individuals is a further argument to propose bariatric surgery, and even more so when diabetes is difficult to manage by medical means and other weight-related complications are present. Bariatric surgery is associated with a better cardiovascular prognosis and reduced mortality, even though acute and long-term complications may occur. The observation that surgical rerouting of nutrients triggers changes in the release of incretin hormones that, in turn, ameliorate the diabetic state in the absence of weight loss has led to the recent development of innovative surgical procedures. Thus, bariatric surgery may be said to be progressing towards so-called 'metabolic surgery', which merits further evaluation in patients with T2DM within a multidisciplinary approach that involves both surgeons and endocrinologists.Keywords : Bariatric surgery ; Gastric bypass ; Gastroplasty ; Obesity ; Type 2 diabetes ; Review RésuméChirurgie bariatrique chez les patients atteints de diabète de type 2: bénéfices, risques, indications et perspectives L'obésité joue un rôle-clé dans la physiopathologie du diabète de type 2 (DT2) et l'obtention d'une perte de poids est un objectif majeur, bien que difficile à atteindre avec les moyens médicaux. La chirurgie bariatrique a apporté la preuve de son efficacité pour induire un amaigrissement marqué et soutenu, qui s'accompagne d'une amélioration du contrôle glycémique et assez souvent d'une remission du diabète. La dérivation gastrique avec l'anse de Roux-en-Y apparaît être plus efficace chez les patients diabétiques que la simple technique restrictive qu'est la gastroplastie calibrée. Ceci peut s'expliquer non seulement par une perte pondérale supérieure, mais aussi par des modifications hormonales spécifiques. En effet, une augmentation des concentrations de GLP-1 (glucagon-like peptide-1) et de GIP (glucose-dependent insulinotropic polypeptide) avec la dérivation permet d'améliorer la fonction de la cellule β et la réponse insulinosécrétoire, en plus de la diminution de l'insulinorésistance consécutive à l'amaigrissement. La présence d'un DT2 chez un sujet obèse est un argument supplémentaire pour proposer une chirurgie bariatrique, d'autant plus qu...
Mots clés : Chirurgie bariatrique -Chirurgie métabolique -Dérivation gastro-intestinaleDiabète de type 2 -Hormones digestives -Incrétine -Obésité SUMMARYBariatric surgery has proven its efficacy to obtain a marked and sustained weight loss and dramatically improve metabolic control in obese patients with type 2 diabetes. The frequently observed remission of diabetes occurs very early, before any significant weight reduction. Increasing evidence suggests that this favourable effect results from profound changes in gut hormones involved in the regulation of energy intake behaviour and glucose homeostasis rather than simply from mechanical food restriction or malabsorption imposed by the surgical procedure. These hormonal changes result from partial stomach amputation (leading to reduced ghrelin secretion), from bypass of duodenal-jejunal foregut (leading to reduced secretion of still unknown factors that may counteract insulin secretion and/or action) and from an earlier contact of food with hindgut (leading to enhanced secretion of incretin hormones such as glucagon-like peptide-1 -GLP-1 -by the ileal L cells, neuropeptide YY and oxyntomodulin). The better knowledge of these pathophysiological mechanisms, especially well studied with Roux-en Y gastric bypass, resulted in recent innovation in the technical procedures leading to a shift from bariatric surgery to metabolic surgery.
added to an excess of methylmagnesium iodide over a period of five minutes with rapid stirring. The mixture was hydrolyzed by adding ice and dilute hydrochloric acid. The organic layer was dried and evaporated on the steam-bath. The colorless oil which remained after evaporation was crystallized from petroleum ligroin. The melting point was 75-77', yield 1.02 g. This compound was not further investigated. Two meso Forms of 2,5-Diphenyl-4-methyl-4-tetrahydro-pyrano1.-Eighty ml. of a benzene solution containing 1.1 g. of cis-2,6-diphenyl-4-tetrahydr~pyrone~ was added over a period of 20 min. to a solution of an excess of methylmagnesium iodide in ether which was being stirred rapidly. The reaction was allowed to proceed for 20 min. and hydrolyzed with ice and diluted HC1. The organic layer was dried and evaporated on a steam-bath and the residue chromatographed on the Magnesol-Celite column. A fraction of 20 mg. melting a t 67-69', which we believe to be the meso-1-compound, was followed by a larger fraction of meso-2-compound weighing 140 mg. which melted from 142-145'. This latter fraction proved to be identical with the material from the t-butyl alcohol-benzaldehyde reaction by mixed melting point.2,6-Diphenyl-J ,5-dimethyl-4-ethyl-4-tetrahydropyranol.--An excess of ethylmagnesium bromide in 180 ml. of ether was added to 11 g. of 2,6-diphenyl-3,5-dimethyl-4-tetra-hydropyrone8 dissolved in ether. After reaction, the material was hydrolyzed with NH,Cl solution and the product recovered and crystallized from petroleum ligroin; yield, 9 g., m.p. 177-178'. This substance is identical with that from the acid condensation; the mixed melting point showed no depression.
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