Abstract
Although type 2 diabetes mellitus (T2DM) has been traditionally viewed as an intractable chronic medical condition, accumulating evidence points towards the notion that a complete remission of T2DM is feasible following a choice of medical and/or surgical interventions. This has been paralleled by increasing interest in the establishment of a universal definition for T2DM remission which, under given circumstances, could be considered equivalent to a “cure”. The efficacy of bariatric surgery in particular for achieving glycemic control has highlighted surgery as a candidate curative intervention for T2DM. Herein, available evidence regarding available surgical modalities and the mechanisms that drive metabolic amelioration after bariatric surgery are reviewed. Furthermore, reports from observational and randomized studies with regard to T2DM remission are reviewed, along with concepts relevant to the variety of definitions used for T2DM remission and other potential sources of discrepancy in success rates among different studies.
Highlights
During the last decades, obesity has reached epidemic proportions in both the developing and the developed world [1]
Overall and visceral adiposity are implicated in the pathogenesis of insulin resistance and type 2 diabetes mellitus (T2DM) [2] and epidemiological trends for obesity are paralleled by a propensity towards a higher prevalence of T2DM [3,4]
There was a low absolute number of participants achieving a notable loss of weight in the cohort of Diabetes Remission Clinical Trial (DiRECT) participants; just over 15% of participants retained a loss of ≥ 15 kg after 2 years while over half did not achieve relevant weight loss (< 5 kg) [18]
Summary
Obesity has reached epidemic proportions in both the developing and the developed world [1]. The fact that an improvement in glycemic indices is observed as early as within a few days post-operatively, before any clinically significant weight loss is achieved, suggests the presence of weight-loss independent mechanisms of metabolic amelioration following bariatric surgery. The acute drastic caloric restriction in the post-operative period may partly account for these effects, since it may contribute to normalization of plasma glucose levels, improvement in beta cell function, and enhancement of hepatic insulin sensitivity in patients with T2DM [23,24]. Gut peptide dynamics including humoral satiety signals and mediators of the incretin effect (which is impaired early in the course of T2DM) may undergo robust changes following both VSG [25] and RYGB [26,27] This is presumably due to the accelerated contact of ingested nutrients with specialized entero-endocrine cells residing in distal parts of the gastrointestinal. Additional factors with a presumed weight-loss-independent role in metabolic improvement post-surgery include increased glucose utilization from the intestine, and alterations of gut microbiota [35]
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