الفهرس 
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Abstract
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UMMARY
he dramatic rise in the prevalence of Metabolic Syndrome 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, increased in Blood Pressure and abnormalities in Lipid Profile.
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.
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
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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 OAGB) improves insulin sensitivity.
Rutledge introduced laparoscopic mini gastric bypass (OAGB) 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
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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 OAGB but 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-
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incretin hormones) from nutrient, leads to reduction in levels of ant-incretin hormones and so, improve insulin secretion and glycemic control. The superiority of OAGB on SG in diabetes remission may be mainly attributed to the foregut mechanism (beside the more prominent hindgut mechanism.
In our study, we aimed to compare between laparoscopic mini-gastric bypass and laparoscopic sleeve gastrectomy regarding the efficacy of control of type 2 D.M, Hypertension and Hyperlipidemia in obese patients. It is a prospective study which was done between April 2022 – October 2022 at Ain Shams university hospitals, Cairo, Egypt.
This study included 60 obese patients with type 2 D.M with one or both of the following (Hypertension and Hyperlipidemia) and divided into two groups-:
group (1): (30 patients) treated by laparoscopic Sleeve gastrectomy.
group (2): (30 patients) treated by laparoscopic One anastomosis- Gastric Bypass.
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, the drain is removed after tolerating oral fluid intake and no leakage
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is detected by gastrografine study. And patient discharged after full ambulation and proper oral fluid intake.