The improvement in their diabetic status. Bariatric surgeries performed

The purpose of this research is to confirm that laparoscopic Sleeve Gastrectomy (LSG) can be used to control
type 2 diabetes in obese patients with the optimum
nutritional support that is based on adequate protein intake to assure
healthy safe weight loss. The
goal for treating type 2 diabetes is to improve the symptoms and to prevent
long-term complications such as neuropathy, nephropathy, retinopathy and other micro
and macro-complications. This goal is achieved by strict continuous
control of blood glucose levels via weight loss, diet, exercise, and medications. When both dietary and medical therapy
fails to control diabetes, bariatric surgery
considered for its sustained weight loss and improvement in the quality of life.  LSG offers a great opportunity for major
weight loss for people with obesity (with BMI
of 30 associated with other co-morbidities) and super-obese patients (with BMI
more than 60) or simply those who failed
other methods to lose their weight.

According to the American Association for Metabolic
and Bariatric surgery, ASMBS (2017) it has been found that:

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who underwent bariatric surgery showed significant improvement in their
diabetic status. Bariatric surgeries performed in more than 135,000 patients
were found to affect type 2 diabetes with the following mechanisms:

Ø  Surgery
improves type 2 diabetes in nearly 90 percent of patients by:

Achieving low blood sugar levels

Reducing both the dosage and type
of medication used to treat diabetes (oral or injections)

Better improvement in most
diabetes-related health complications 

Ø  Surgery
causes type 2 diabetes to go into remission in 78 percent of individuals by:

Achieving better reduction in
blood glucose levels to normoglycemia

Decrease or eliminate the need for diabetic medications

Eliminate the need for diabetes

Ø  Health

Longer remission or improvement
of T2DM for years


Also, ASMBS (2017) has found the following:

Sleeve gastrostomy appears to have satisfying
outcomes of weight-loss-independent
effects on glucose metabolism and also causes some
changes in gut hormones that favor improvement in diabetes. The percentage of
diabetes mellitus remission is considered high and significant after LSG (60%
and more) that is resembling the results after gastric


Defining terms

A clear and complete
definition of the focal terms mentioned in this proposal is essential. As
stated by Mahan and Raymond, 2017 Diabetes Mellitus – (DM) “is defined by a
group of diseases characterized by high blood glucose concentrations resulting
from defects in insulin secretion, insulin action, or both. Type 2 Diabetes – (T2DM)
characterized by a combination of insulin
resistance and beta-cell failure”. Laparoscopic Sleeve Gastrectomy – (LSG) –
often called the sleeve – “is performed by removing approximately 80 percent of
the stomach. The remaining stomach is a tubular pouch that resembles a banana
that is narrow and provides a much smaller reservoir for food” (ASMBS, 2017). For the monitoring of diabetes control according to the
American Diabetic Association, ADA (2017): “1- Glycosylated Hemoglobin – (HbA1c
or A1C) is a blood test that gives a picture of the average blood glucose
(blood sugar) control for the past 2 to 3 months. The result gives a good idea
of how well diabetes treatment plan is working
and Fasting Plasma Glucose – (FPG) is a blood test that checks fasting blood
glucose levels”.


Justification of the Research

As it is stated by ASMBS, (2017):

“In 2011, a multidisciplinary team of specialists’, e.g., diabetologists, endocrinologists,
surgeons and public health experts gathered at the 2nd. World Congress on Interventional Therapies for Type 2 Diabetes
in New York City. According to the supporting evidence
presented by these experts, The International Diabetes Foundation (IDF)
released a Position Statement asking for the early consideration of bariatric
surgery as a treatment of T2DM.

In summarizing of the released document from
the IDF:

with the behavioral and medical treatments, bariatric surgeries present a
primary opportunity to improve the control of diabetes for patients suffering
from obesity.

risk of mortality and complications after bariatric surgery is considered low
and resemble other well-accepted
procedure such as gallbladder surgery.

surgery is considered a proper treatment for people suffering from obesity and
T2DM, and not able to reach their target goals with their medical treatments.

of a BMI 30-35 with poor control of T2DM on optimum medical interventions, along with major cardiovascular risk factors, must
be considered for bariatric surgery as another line of therapy.

of T2DM by bariatric surgery is cost-effective.

with T2DM and a BMI of 35 or more, surgery must be an acceptable choice for

surgery for patients suffering from T2DM should be implemented within clear guidelines that include a multidisciplinary plan of care
approach constitute from medical experts, follow-ups
and clinical audit, proper patient, and
family education to be given and
explained well, along with an efficient surgical

Based on the above statement, this proposal is aiming to confirm and
support the use of laparoscopic sleeve gastrectomy to control T2DM with proper
nutritional intervention.  

Research Methodology

Richdeep et al.
(2010) conducted a systematic review of
all studies reported from 2000 to April 2010. In his review, it is suggested that
in obese patients, a failure might occur of beta-cells in the pancreas to
secrete adequate levels of insulin –due to the excess body fat – to compensate
for the insulin resistance in peripheral tissues, which ultimately leads to
type 2 DM.


The possible mechanism of action in the weight loss post-LSG is believed to be secondary to the restriction of food intake by the small gastric
reservoir. Currently, the theory of hormonal changes has been postulated to be involved as well. It has been found in the
reviewed studies, a marked reduction of fasting ghrelin levels after LSG
surgery. Ghrelin is a hormone produced primarily by the gastric fundus, which
inhibits insulin secretion and blocks hepatic insulin signaling. It was stated that by reducing ghrelin levels
and its “insulinostatic effect,” the
islet cells of the pancreas will be probably able to secrete additional insulin
by increasing the maximal capacity of glucose-induced insulin release. (Richdeep
et al. 2010).

“This systematic review study revealed that there are 27studies and
673 patients were analyzed. The baseline mean body mass index for the 673
patients was 47.4 kg/m2 (range 31.0 –53.5). The mean percentage of excess
weight loss was 47.3% (range 6.3–74.6%), with a mean follow-up of 13.1 months
(range 3–36). DM had resolved in 66.2% of the patients, improved in 26.9%, and
remained stable at 13.1%. The mean decreases
in blood glucose and hemoglobin A1C after sleeve gastrectomy was _88.2 mg/dL
and _1.7%, respectively” (Richdeep et al. 2010).

The types of studies which were reviewed
included human retrospective and prospective case series. Those studies that were considered targeted a population of adult (above18
years old) male or female patients with type 2 DM who had undergone LSG. To
consider a patient is obese are those with a BMI more than 30 kg/m2 and they were included. The focal intervention was LSG
as a solitary procedure or as a first-stage procedure in all bariatric
procedure. The outcomes that were measured included both primary and secondary
outcomes. The primary outcome was the resolution
of type 2 DM that was defined as
discontinuation of all hypoglycemic medications and/or
insulin and normal readings of both fasting plasma glucose level as well as
normal postprandial glucose, in addition to normal hemoglobin A1c (HbA1c). The
secondary outcomes measured the change in BMI, percentage of excess weight
loss, and change in glucose levels, HbA1c levels, mortality, and postoperative
complications. (Richdeep et al. 2010)

In this proposal, the focus is mainly about the outcome of the
surgery which is established by rapid and sustained weight loss, excessive fat
loss, therefore improving the diabetes control by increasing the sensitivity of
insulin in addition to the adequate and sufficient amount of insulin levels. Such outcomes cannot be achieved easily by the only
diet and exercise especially for morbidly obese patients who are mostly suffering
from limited mobility (for having arthritis, back or knee pain, etc.) or other
comorbidities that restrict, restrain and delay the weight loss, in addition to
the muscle wasting for not complying to the recommended diet program (due to
the desire of fast weight loss that is not usually achieved by most healthy
diet program or due to the poor well of the patients to follow the given
instructions).  Nutritional
intervention and support are essential during
all stages and steps of the surgery (as both pre and post op). Focusing on
consuming the required amount of protein and other needed nutrients for maintaining
optimum nutritional status during the journey of weight loss. (Richdeep et al.


Supporting Evidence

Both dietary and medical therapy for severely obese patients has
limited short-term success and almost non-existent long-term success.
Therefore, surgical intervention must be considered to eliminate the increased
risk of complications from type 2 diabetes. Bariatric surgery has been a
popular tool in the war against obesity by medical personnel and patients who
failed the conventional treatment (lifestyle changes and medications). Thomas
et al. (n.d.)

Weight loss surgery results in greater and sustained weight loss
than conventional treatment and leads to
improvements in quality of life and obesity-related
diseases such as hypertension, sleep apnea, dyslipidemia, and many medical
illnesses. Thomas et al. (n.d.)

There evidence
support LSG as a surgical option for bariatric patients to produce long-term
sustainable weight loss, with the improvement
of T2DM, is increasing.   Richdeep et al. (2011), reviewed several studies for
LSG, and stated in his article that there was an assessment of LSG in 17 obese
(BMI >50) patients with T2DM and demonstrated
an 80% resolution rate for T2DM. He revealed as well that a study was completed for diabetic patients who went
under LSG, 75 high-risk morbidly obese (BMI >60) patients with T2DM. His findings were
that those patients had a percentage excess weight loss of 46% and had 81% T2DM
resolution following LSG at 12 months follow-up. He also reviewed a prospective
study, which included 39 patients with T2DM. These patients had a T2DM
resolution rate of 81%, with a reduction of HbA1c levels from 7.4 to 6.9. Shah
and colleagues evaluated LSG in 58 obese (mean BMI 45) T2DM and found an
impressive 96% resolution rate for T2DM. HbA1c levels in these patients dropped
on average from 8.4% to 6.1 %.

et al. (2010) also studied the risks of surgery such as malabsorption and
internal hernias postoperatively are which has been found to be minimal.
Dumping syndrome has not been reported as
a postoperative issue. “The operative mortality at 30 days was .36% for all LSG
(not only DM patients) procedures (4 deaths of 1117 patients) based on 16
studies. Postoperative complications such as bleeding occurred in 1.79% (20 of
1117 patients). Postoperative abscess or infection occurred in .27% (3 of 1117
patients). Postoperative leaks occurred in 22 of 1117 patients (1.97%)”. Based on those early data and results, it is established in Richdeep et al. (2010) review that laparoscopic Sleeve Gastrectomy (LSG), a less technically
complex procedure, is being considered as a surgical option for obese patients.

According to Michell et al. (2012) “protein
intake should be quantified periodically by the medical team to ensure adequate
education and implementation of the prescribed diet.



Arguments to Negate the Fact

The first line treatment for type 2 diabetes is weight loss with diet (that is basically meant to follow a healthy meal planning) and exercise
(regular exercising helps burning excess calories, managing weight thus
improves control of blood glucose levels).  Once diet and exercise – lifestyle changes – are
not sufficient to control blood glucose, medications will be added. Mechanism of actions varies by
increasing insulin secretion, and/or by
improving the sensitivity of insulin or decreasing the absorption of
carbohydrates from the gastrointestinal tract
or decreasing glucose production from the liver. In patients with poor control
of diabetes despite lifestyle changes and medications, insulin must be included
in the treatment. Surgical intervention for controlling diabetes is considered
secondary to the conventional treatments after lifestyle changes and
medications. Thomas et al. (n.d.)

the other hand, the American Society for Nutrition, ASN (n.d.) has released a

In 2002, the Diabetes Prevention Program (DPP),
funded by the National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK), showed that an intensive lifestyle intervention that included medical
nutrition therapy, weight loss of 5-7 percent, and exercise was more effective
in preventing the progression from pre-diabetes to diabetes than was drug therapy
alone. During the study, the chance of developing diabetes was 58 percent
lower in the lifestyle intervention group, but only 31 percent lower in the
group receiving drug therapy.