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Abstract: Background: The aim of this study was to evaluate the possible role of sleeve gastrectomy (SG) per se in the reversibility of diabetes.Methods: Insulin secretion and peripheral insulin sensitivity using the intravenous glucose tolerance test (IVGTT) were assessed in 18 obese type 2 diabetic patients and in 10 nondiabetic obese patients before and 3 days after SG, before any food intake and any weight change occurrence. At the same time, ghrelin, GLP-1, and PYY levels were determined. Results: In diabetic patients who had the disease less than 10.5 years, the first phase of insulin secretion promptly improved after SG. The early insulin area under the curve (AUC) significantly increased at the postoperative IVGTT, indicating an increased glucose-induced insulin secretion. The second phase of insulin secretion (late AUC) significantly decreased after SG in all groups, indicating an improved insulin peripheral sensitivity. In all groups, pre- and postoperatively, intravenous glucose stimulation determined a decrease in ghrelin values and an increase in GLP-1 and PYY values. However, in the group of patients with disease duration >10.5 years, the differences were not significant except for the late insulin AUC. Postoperative basal and intravenous glucose-stimulated ghrelin levels were lower than preoperative levels in all groups of patients. Basal and intravenous stimulated GLP-1 and PYY postoperative values were higher than preoperative levels in all groups. Conclusions: Restoration of the first phase of insulin secretion and improved insulin sensitivity in diabetic obese patients immediately after SG, before any food passage through the gastrointestinal tract and before any weight loss, seem to be related to ghrelin, GLP-1, and PYY hormonal changes of possible gastric origin and was neither meal- nor weight-change-related. Duration of the disease up to 10.5 years seems to be a major cut off in the pathophysiological changes induced by SG. A “gastric” hypothesis may be put forward to explain the antidiabetes effect of SG.

Abstract: Background: Laparoscopic sleeve gastrectomy (SG) was originally used as a bridge to definitive surgery in high-risk patients. Recently it has been considered as a stand-alone procedure due to its effectiveness on weight loss and comorbidities resolution. This study was designed to evaluate the results of SG on complications, body mass index (BMI), and comorbidities resolution in 300 consecutive obese patients and to analyze the lesson learned from this experience. Methods: From October 2002 to November 2009, 300 patients underwent SG. In the first 100 cases (group 1: mean BMI, 54.4 ± 9.3), SG was intended as a first stage of biliopancreatic diversion with duodenal switch in high risk super-obese patients. In the last 200 cases (group 2: mean BMI, 45.5 ± 7.3), SG was intended as a definitive procedure. No routine reinforcement was performed in group 1. In group 2, oversewn reinforcement was performed routinely. SG was redo surgery in 21 patients (7%). Results: Mean operative time was 119 ± 48.6 min in group 1 and 72 ± 33.8 in group 2. Conversion rate was 0.6% (massive hepatomegaly). Mortality was 0.6%. Major postoperative complications were registered in 15 patients in group 1 and 11 in group 2. In 3 cases, a reoperation was needed. The mean BMI in group 1 was 46, 43, 39, and 31 at 6, 12, 24, and 36 months, respectively. In group 2, the mean BMI was 32.9, 30.6, and 31.7 at 6, 12, and 18 months. At 12 months, the diabetes, hypertension, and OSAS were cured on 69%, 62%, and 50% in group 1 and 88%, 57%, and 58% in group 2. In group 2, no patient required second stage. Conclusions: SG is a safe and effective treatment for morbid obesity at mid-term follow-up. SG is effective for comorbidities resolution, especially for the treatment of diabetes. Suture line reinforcement allows a significant reduction of bleeding.

Background: Bariatric surgery depends on complete preoperative study of morbid obesity, in order to obtain the treatment of choice. A multidisciplinary group was founded in 1998 at the University of Siena. Methods: During 1998, 16 patients, with median weight 121.8 � 31 kg and median body mass index (BMI) 43 � 6, underwent bariatric surgery. A multidisciplinary assessment was used in order to evaluate psychological status, food intake problems and patient compliance, and hemodynamic, respiratory, metabolic and arthritic functions. 13 patients were submitted to laparoscopic surgery: in 11 adjustable gastric banding was performed and 2 were submitted to a vertical gastroplasty plus adjustable gastric banding.Three patients were operated via traditional laparotomy, due to previous abdominal surgery in 2 cases (submitted to an adjustable gastric banding) and one woman was submitted to a bilio-intestinal bypass according to the Hallberg technique, for her psychiatric troubles and coexisting systolic hypertension and uncontrolled diabetes. Monthly follow-up for each patient continues after 6 months. Results: No morbidity or mortality has occurred. The median weight loss at three months, was 19.5 kg. Two cases required injection of 1 ml more of fluid into the port, respectively at 4 and 9 months. Fifteen days after surgery, seven patients (46%) had vomiting episodes, due to rapid food intake. All patients have shown an improvement of their comorbidities after surgery. Conclusion: Early results via the multidisciplinary team and laparoscopic banding have been satisfactory thus far.