الفهرس 
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Abstract
The dramatic rise in the prevalence of obesity and diabetes has become a major global health issue. The problem is complex and will require strategies at many levels to prevent, control and manage. It is well known that obesity has profound effect on tissue sensitivity to insulin and so, leads to glucose intolerance.
In addition to behavioral and medical approaches, various types of surgery on the gastrointestinal tract, originally developed to treat morbid obesity (bariatric surgery), constitute powerful options to ameliorate diabetes in severely obese patients, often normalizing blood glucose levels, reducing or avoiding the need for medications and providing a potentially cost-effective approach to treating the disease. It is proved that the bariatric surgery is considerd the most effective and long acting treatment modality for type 2 diabetes mellitus.
It is difficult to identify the most effective operation based on patient characteristics and comorbidities. Furthermore, little is known regarding the effect of the various surgical procedures on glycemic control and on type 2DM remission.
Sleeve Gastrectomy is a restrictive procedure. The reduction of the size of the stomach results in a powerful restrictive weight loss. As a result, patients feel full after a very small amount of food, and therefore lose weight because they eat less. There are also significant effects on the hunger mechanisms that make the weight loss seen with the sleeve gastrectomy even better than would be seen just with a small stomach pouch. Hunger is favorably affected because there is a reduced capacity to produce Ghrelin, a hormone secreted by the stomach and proximal small bowel, particularly before meals that plays a role in how you feel and relieve hunger.
Ghrelin hormone has an anti-insulin effect so, postoperative reduction in ghrelin hormone (by excision of fundus in SG, exclusion of it in MGB) improves insulin sensitivity.
Rutledge introduced laparoscopic mini gastric bypass (LMGB) with the purpose to carry out an ideal weight loss operation which should be effective, easy to perform and safe. The procedure consists of a long lesser-curvature gastric tube with a gastrojejunostomy performed 180–220 cm distal to the Treitz’ ligament.
It was thought that weight loss is the main mechanism of diabetes control after bariatric surgery, but now it is well realized that the gut is considered an endocrine organ secreting many hormones which has the upper hand in this action so, the patient can experience diabetes remission even before he lost the major excess weight.
It is clear now that the gastrointestinal tract plays a very important role in control of energy homeostasis through signals from the gastrointestinal tract which are important regulators of gut motility, digestion, absorption and satiety and so, the long-term control of body weight. Furthermore, the specialized enteroendocrine cell in the gastrointestinal mucosa have important roles in regulating energy intake and glucose homeostasis through their actions on peripheral target organs, including the endocrine pancreas.
The most important evidence that there is a link between the gut and the endocrine pancreas is called incretin effect. Incretin effect is the phenomenon of insulin secretion enhancement in response to glucose intake and this effect may be responsible for up to 70 % of postprandial insulin secretion. This link is termed enteroinsular axis. The two most important incretins are Glucose-dependent insulinotropic polypeptide (GIP) and Glucagon like peptide-1 (GLP.1). Both hormones powerfully enhance insulin secretion in response of ingested meal and so, improve insulin glycemic control.
The hindgut especially distal ileum is the major source of incretin hormones GLP-1 and PYY which have major insulinotropic effect. In obese patients the levels of these incretin hormones decrease leading to insulin resistance and hyperglycemia. After SG and MGB, there is dramatic improvement in incretin level due to rapid delivery of undigested nutrients to the distal bowel which in turn stimulates L-cells to secrete GLP-1 and PYY.
Although the hindgut theory is more prominent with MGB but Melissas and his colleagues found in their study that the gastric emptying of food to the duodenum is accelerated after SG although the pylorus is preserved.
Foregut theory has a vital role in glucose homeostasis. After gastric bypass, bypassing and exclusion of proximal bowel (duodenum and proximal jejunum which are the site of ant-incretin hormones) from nutrient, leads to reduction in levels of ant-incretin hormones and so, improve insulin secretion and glycemic control. The superiority of MGB on SG in diabetes remission may be mainly attributed to the foregut mechanism (beside the more prominent hindgut mechanism.
In our study, we aim to compare between laparoscopic mini-gastric bypass and laparoscopic sleeve gastrectomy regarding the efficacy of control of type 2 D.M in obese patients. It is a randomized controlled study which was done between December 2014 – December 2016 at Ain Shams university hospitals, Cairo, Egypt.
This study included 60 obese patients with type 2 D.M and randomly divided using closed envelopment method into two groups:-
group (1): (30 patients) treated by laparoscopic Sleeve gastrectomy.
group (2): (30 patients) treated by laparoscopic Mini-Gastric Bypass.
The patients included in this study fulfilled the following criteria:
1- They were willing to give consent and comply with the evaluation and treatment schedule.
2- Their age > 18 years old.
3- Their body mass index (BMI) ≥30 kg/m2
4-Type 2 D.M
The patients who were excluded from the study:
• Endocrine abnormalities: e.g. hypothyroidism, Cushing syndrome.
• Previous bariatric operations.
• Major upper abdominal surgery.
• Type 1 D.M.
• Age below 18 years old.
• Pregnant or lactating females.
• Patient with contraindications for insufflation as those with sever cardiovascular or sever restrictive respiratory diseases.
• Patient with significant abdominal ventral hernia.
• Patient with major psychiatric illness
All patients were subjected to Preoperative workup including complete history taking, complete physical examination, laboratory tests, imaging investigation (chest X-ray, Abdominal U.S, Pulmonary function test, echocardiography) and UGI endoscopy (if needed).
In the first group of sleeve gastrectomy, the operation was done by laparoscopy starting with gastrolysis of greater omentum along the greater curvature by Ligasure (3-6 cm proximal to the pylorus) to the gastro-esophageal junction and vertical gastrectomy was performed by endoGIA stapler along the greater curvature from the distal antrum to the angle of Hiss including the complete fundus guided by a 36 mm French bougie as a calibration tube.
In the second group of mini gastric bypass, the operation was done by laparoscopy (except one case which was converted to open) starting with creation of a small vertical gastric pouch along the lesser curvature just proximal to the antrum to the angle of Hiss by endoGIA guided by caliberation tube 36 French. Then Measurement of 200 cm of jejunum from the ligament of Treitz was done and gastrojejunostomy is performed using endostapler. The residual stoma is closed manually with vicryl 2/0 continuous suture.
Postoperatively, we monitored the vital signs for all patients, low molecular weight heparin during hospital stay was given for patients with BMI > 40 kg/m2 and one dose of one gram of third generation cephalosporin was given for all patients. Clear fluid diet was started once the patient was open bowel, gastrografine swallow is done on fifth day to exclude anastomotic leakage. The drain is removed after tolerating oral fluid intake and no leakage is detected by gastrografine study. And patient discharged after full ambulation and proper oral fluid intake.
Follow up of visits in outpatient department at 1month and then at 3, 6 and 12 months for: BMI with each visit, measurement of HbA1c and FBS, at 3, 6 and 12 months and follow up of changes in dose or discontinuation of anti-diabetic medications.
The final outcome of each group (SG & MGB) was considered either resolved, improved or unchanged. Resolved if HBA1c < 6.5% and FBS < 126 mg/dl with no postoperative diabetes medication. Improved if HBA1c and FBS levels decreased but still above endpoint range (6.5% and 126 mg/dl respectively) but with no postoperative diabetes medication. D.M was considered unchanged if no improve in HBA1c and FBS with still on postoperative medication.
The mean operative time of group 1 (sleeve gastrectomy) was 85 minutes ranging between 50-120 minutes while in group 2 (minigastric bypass) was 130 minutes ranging between 90 -160 minutes and there is no significant statistically difference between two operations in mean operative time
Intraoperative bleeding was non-significant in both groups with average was 50 cc, no case in group 1 (SG) was converted to open while one case in group 2 (MGB) had been converted to open as regard wound infection, it was reported in one case in MGB group but not reported in SG group. Two cases in SG group and four cases in MGB group developed Chest infection. Gastritis induced vomiting was reported in two cases in SG group while in MGB group, two cases developed biliary gastritis manifestation. One case in each group developed postoperative gall stone and planned for cholecystectomy.
In analysis of postoperative data, postoperative hospital stay in SG group ranged between 1 to 3 days with the mean 2 days while in MGB group, hospital stay ranged between 1 to 5 days with the mean 3 days but this difference was statistically non-significant between two groups
The mean BMI loss after one year in MGB (19.67 ± 7.17 kg/m2) was more than BMI loss in SG (18.47 ± 5.14 kg/m2) but this difference was statistically non-significant.
As regard diabetes remission effect, MGB has a better effect than SG in diabetes remission detected by that the mean FBS DROP after one year in MGB (37.80 ± 6.41 mg/dl) was more than after SG (29.93 ± 12.84 mg/dl) and this difference of DROP was highly statistically significant (p value <0.004). The mean HBA1c DROP after one year in MGB (2.33 ± 0.48 %) was more than in SG (2.01± 0.59 %) and this difference of DROP was statistically significant ( p value <0.024).
So, Complete resolution of diabetes occurred in MGB cases in 80% compared to 66.7% in SG cases at 12 months and cases with no remission in D.M was 0% in MGB and 6.7% with SG.
Also, we found that effect of MGB on diabetes resolution was faster and earlier than SG reflected by cases with early diabetes resolution at 6 months was 46.7% with MGB in comparison to 20% with SG.
In our study we also, identified the possible predictors for type 2 D.M remission for both operations collectively by univariate analysis. The better diabetes resolution effect was noticed with younger age, male gender, cases on oral hypoglycemic medication rather than who on insulin, central distribution of obesity, negative family history of D.M, higher preoperative C-peptide level (indicate more preserved functional pancreatic β cells), shorter duration of D.M ( <5 years) and better preoperative diabetic control status (HBA1c < 8.5 %). While by multivariate analysis OHG, C peptide >3 ng/ml and duration >5 years are considered the most independent significant predictors for diabetes resolution and other significant predictors were dependent on them.
The study also revealed positive correlation between BMI loss and diabetes remission but statistically nonsignificant (may indicating presence of other more important mechanisms of postoperative diabetes resolution rather than weight loss).