12^th European Diabetes Congress

Biography

Biography: Kyung Yul Hur

Abstract

The most potent therapeutic modality for type 2 diabetes is rerouting of food passage or restriction of food intake by surgery. But, the Achilles heel of surgery is surgical risk itself.  So far, aggressiveness and morbidity were excusable in surgical treatment because it was final modality for most cases. But, in metabolic & bariatric surgery, it’s just the beginning of treatment. We need to carefully weigh the pros and cons before surgical intervention. Recently, we have found acceptable operative procedure for cure of diabetes. Before discussing about the mechanism of surgery, it would be better to open our published data for better understanding. The numbers of patients who have been followed up for more than 5 years were 60. Among them, 37 patients were analyzed. Outcomes of preoperative, post-operative 1st year and 4th year follow-up were included. The HbA₁C, HOMA-IR, Matsuda index and acute insulin response were analyzed to evaluate blood glucose control, insulin resistance, insulin sensitivity and pancreatic beta cell function. Perioperative incretin changes were evaluated in 12 non-obese subjects to compare at before the surgery and 1 month after by ELISA. Preoperatively, mean age was 48, BMI was 24.5 and HbA₁C level was 9.1%. 30 patients (81%) have shown decreased HbA₁C lower than 6.9% during the follow up. HbA₁C decreased continuously after the surgery. HOMA-IR decreased at first year after the surgery and then increased within the acceptable range.  Interestingly, insulin sensitivity, which is represented by Matsuda index, sharply increased at first year and then recovered. The major cause of type 2 diabetes in East Asia has been thought to be impaired insulin secretion rather than increased insulin resistance. Modulation of gastric emptying in response to signal from small intestine prevents dumping syndrome, marginal ulcer, diarrhea, bile reflux to stomach and so forth. But, care should be taken to pyloric preservation. Meticulous analysis of published data for duodeno-jejunal bypass, anti-diabetic effect of surgery is extremely inconstant between paper to paper. Subtle difference between two groups was whether preservation or exclusion of pyloric ring. In other word, completeness of duodenal mucosal exclusion is possible determinant. Incomplete exculsion of duodenal tissue is directly connected with recurrence of hyperglycemia. Unique pattern of mucosal regeneration is key element of recurrence. Intestinal mucosa is replaced with its progeny adjourn to another villi within 5 days. Anastomosed jejunal epithelium becoming duodenal epithelium will be a reasonable thesis. Best design of rerouting is preservation of pyloric digestive function simulaneously complete exclusion of duodenal mucosa. he pyloro-enteric anastomosis technique guarantees both anti-diabetic effect and functional preservation. Incretin secreting entero-endocrine cells never found in pyloric ring covered with gastric mucosa. Guarantee of anastomosis safety by 5cm epigasrtic incision with extracorporeal hand-sewing is another benefit. Result is more than better for 7 patients underwent single anastomosis pyloro-enterostomy. Long-term follow up for effectiveness and safety is mandatory.