Diabetes mellitus (DM) is one of the most common chronic diseases, which is recognized as non-infectious epidemic by experts of the World Health Organization (WHO). The number of people with diabetes now exceeds 250 million people, including approximately 90% of patients with type 2 diabetes [Bristow S. et al., 2009]. During the last 20 years the number of diabetes patients in the world has increased by 6 times. At this rate of growth in 2025 the number of diabetes patients in the world will exceed 300 million people [Mokdad AN, Ford E.S., 2003].
Type 2 diabetes is characterized by the development of severe complications, leading to total disability and premature mortality. According to the study of Cosí of Diabetes in Europe type 2 variety of complications were in 59% of patients, in 23% of patients at the same time they revealed two of complications and three complications of type 2 diabetes in 3%, 55% of which is accounted to cardiovascular and cerebral lesions [Liebl A. et al., 2002]. Cardiovascular disease remains the leading cause of disability and premature death at type 2 diabetes. In most developed countries of the world diabetes takes the 3-4 place in the overall structure of mortality and is the leading cause of blindness and visual impairment at adults. In the US and in some European countries the cost of treatment of type 2 diabetes and its complications exceeds 15% of annual health care costs [Lee J.M., et al., 2009].
It is known that excess food and a sedentary lifestyle, leading to an increase in body weight and obesity, contribute to the development and worsening of insulin resistance that is the leading pathogenetic link of the development of type 2 diabetes. Epidemiological studies show a higher prevalence of impaired glucose tolerance (IGT) and diabetes mellitus among people with obesity and a favorable impact of weight loss on carbohydrate metabolism in this patients’ category. The risk of development of diabetes type 2 doubles with obesity of the I degree, 5 times – of the II degree and more than 10 times – of the III degree [Bugrova SA, 2001]. The most significant pathogenetic importance has abdominal fat, as excess fat contributes to the development of metabolic disorders (including hyperinsulinemia, hypertension, hypertriglyceridemia, insulin resistance) [Akhmetov, A.M., et al., 2000].
Low efficiency of glucose-lowering therapy is one of the major unsolved problems of modern clinical diabetology due to clinical inertia of doctors, patients with low adherence to treatment, as well as the limitations and disadvantages of used antidiabetic drugs. [Dzgoeva FH, 2000; Manusharova P.A., 2008; Martyn J.A. et al., 2008].
In 50-60 years of the last century surgery has formed a new brunch, the aim of which was the reduction of body weight in patients with morbid obesity, called bariatric surgery. The accumulation of experience in this area has shown normalizing effect on reducing the body mass index (BMI) on carbohydrate and fat metabolism and decreasing adipose tissue hormone’s concentration both leptin and adiponectin. [Sedletskii Y., et al., 2005]. These data, as well as dissatisfaction with the results of conservative medical treatment account for an interest in the development of surgical technique - the removal of abdominal wall’s excess fat (lipoaspiration).
However, until now a promising method of surgical treatment of type 2 diabetes in obese patients is still little studied. In fact, targeted research to support the effectiveness of lipectomy was conducted. Not enough attention is paid for changes in hormonal status under a decrease of body mass index (BMI) by applying bariatric surgery. Therefore this method is still undervalued and not applied in practice for the treatment of type 2 diabetes.
The data above determine the urgency and the need for further study of the clinical efficacy of surgical repair of abdominal obesity as a new and perspective method for treating patients with diabetes type 2 with abdominal form of obesity.
The purpose of work is to evaluate the possibility of surgical correction of metabolic disorders in patients with abdominal obesity and type 2 diabetes based on the evaluation of carbohydrate and lipid metabolism, certain hormonal parameters and remote results of treatment, as well as by comparing effectiveness of conservative and surgical treatment.
The study was performed on the basis of the Endocrinology ward of the city hospital number 41 in Ekaterinburg. The work is based on the results of examination and treatment of type 2 diabetes clinic by conservative method in 30 patients (9 men and 21 women) suffering from abdominal obesity with a BMI over 30 kg / m2 and a waist circumference (OT)> 94 cm in men,> 80 cm in women . The mean age was 49,1 ± 7,1 years. Obesity I degree was in 46.6% of patients, II - in 33,6%, and III - in 19,8%. The degree of obesity was established in correspondence with generally accepted WHO classification. Patients whose treatment was carried out by conservative method were include in the I (study) group. The II (control) group involved 57 patients (40% men and 60% women), also suffering from abdominal obesity with concomitant type 2 diabetes who undergone surgical correction of abdominal obesity. These results of examination and treatment of patients of group II were taken from scientific papers about bariatric surgery by Voloh MA [Voloh MA .; 2011]. Both groups were comparable in age, sex, body weight, duration of the disease.
Patients in both groups had different comorbidities: coronary heart disease (CHD), arterial hypertension (AH), myocardial infarction (MI), lower-extremity atherosclerotic arterial disease (AAD).
The results of surgical and conservative treatment of patients with obesity and type 2 diabetes indicate significant differences in the dynamics of metabolic disorders and in course of concomitant cardiovascular disease.
Surgical removal of abdominal fat resulted in markedly improved lipid profile indicators, especially in obese patients of the I-II degree. In surgical patients with obesity of the III degree there was observed (within 5 years) significant (p = 0.005) decrease in total cholesterol, whereas after the conservative treatment such changes were not recorded. Similar results were obtained in studies of blood triglycerides. The first year after the surgical correction of excess weight in the examined patients there was showed a significant decrease in atherogenic factor, regardless of the degree of obesity (p = 0.005). In case of conservative treatment atherogenic factor reduction was observed only for 1 month, after which the rate returned to baseline values. A significant increase in the level of high density lipoprotein (HDL) occurred in the surgical patients with obesity I during the first year of observation. Further, as in patients with more severe obesity the increased HDL was significant (p = 0.06). Patients treated by conservative therapy, reduced LDL and VLDL (low density lipoprotein and very low density lipoprotein) levels were observed only during the first 6 months, while in the surgical patients with obesity of the I and II degree there was a sustained reduction in LDL and VLDL, which persisted for 4 years. Positive changes were more pronounced in patients with I and II obesity degree.
Less significant changes in patients with severe obesity can be explained initially by more profound metabolic changes and persistent violation of homeostatic regulatory constants of lipogenesis. Due to carbohydrate metabolism in patients with type 2 diabetes for 3-7 days after surgery there was significant (p = 0.01) decrease in blood glucose on an empty stomach, that was less pronounced in patients with severe obesity. These changes were maintained for further 5 years. Blood levels of immunoreactive insulin (IRI) in patients with obesity-I had significantly decreased by the end of the first week after surgery (p = 0.01) and remained stable during follow-up. Insulin resistance index (HOMA-IR) decreased during the whole observation period, regardless of the severity of obesity (p = 0.001). They noted a steady rise of the index of the functional activity of the insular apparatus of the pancreas B-cell (HOMA-SE) in patients of the control group during the observation after surgery (p = 0.005). In the control group they also observed a positive trend, but the indicators were already sought to the primary (before conservative treatment) for the 2nd year of treatment.
In patients with obese-I there was a significant decrease in cortisol level in the blood after 1 month after surgery (p = 0.05), maintaining for 1 year follow-up. In patients with more severe obesity the value of this indicator decreased significantly after 1 year of follow-up (P = 0.05).
Since testosterone level in male patients depends on the degree of obesity, the surgical treatment of patients with moderate obesity tended to increase testosterone levels at 1 year after surgery (p = 0.065).
Surgery in patients of the control group resulted in a statistically significant reduction in systolic, diastolic, and mean arterial pressure during the entire observation period. After 5 years after surgery the episodes of increase in systolic blood pressure (SBP) of more than 180 millimeter of mercury (mmHg) began to meet less frequently (p = 0.03), and SBP in the range of 140 to 160 mmHg, on the contrary, recorded significantly (p = 0.05) more frequently than before the surgery.
In patients treated by conservative method, a small, but statistically significant (p = 0.05) reductions in SBP occurred only six months after initiation of therapy. In the remaining periods of observation sAp, dAp and MAP showed a significant upward trend. At the end of the observation period in the main group there was an increase in frequency sAp levels of more than 180 mmHg against the backdrop of significant (p = 0.003) increase of moderately high sAP (140-160 mmHg).
In the analysis of chronic coronary disease patterns within 5 years after the operation they did not reveal any new cases of coronary heart disease and myocardial infarction, whereas among patients of the study group during the same period of observation, there had been diagnosed four new cases of coronary heart disease, and 2 cases of developed myocardial infarction.
Scoring the quality of life assessment was carried out a year after the start of treatment, and in the surgical patients they were much higher than the corresponding figure of the study group (conservative treatment). A significant difference was observed at the categories that reflect both the physical and psycho-emotional state. Thus, surgical correction of obesity in patients with type 2 diabetes was accompanied by a significant improvement in indicators such as physical functioning, role-physical limitation of functions, the life force, social functioning, emotional limitation of role functions and mental health (p <0.05). In addition, the majority of patients after surgery were capable of working with high social activity.
Thereby, in patients of the control group, in contrast to the response to conservative therapy, they observed a stable positive effect of operative treatment of obesity in a more significant and persistent lowering of triglycerides, total cholesterol and LDL levels accompanied by increased HDL in the blood serum. In patients of II group during observation time there substantially increased the level of immunoreactive insulin, as well as the estimated index of the functional activity of beta cells against the background of a significant reduction in indicators of insulin resistance, in patients of the study group such positive dynamics was not observed.
The findings also suggest that the surgical removal of excess subcutaneous fat in the anterior abdominal wall promotes stable normalization of carbohydrate and fat metabolism types, reduction of coronary heart disease morbidity and improved course of arterial hypertension, and it also improves the quality of life in patients with abdominal form of obesity and type 2 diabetes. The ineffectiveness of conservative treatment of I-II obese patients and type 2 diabetes, and at the same time, rapid postoperative normalization of carbohydrate and lipid metabolism in a group of surgical patients with I-II obesity, and the stability of the achieved results demonstrate the overall benefits of surgical treatment for this patients category.