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CHOOSING SURGICAL TREATMENT TACTICS FOR PATIENTS WITH TYPE 2
DIABETES
Kholmanova Saygul Isoyevna
Tashkent Medical Academy, Department of Surgical Diseases in Family Medicine,
1st year Master
Shermatova Azima
Tashkent Medical Academy, Department of Surgical Diseases in Family Medicine,
1st year Master
Tavasharov Bahodir Nazarovich.
Scientific supervisor PhD.
Tashkent Medical Academy, Department of Surgical Diseases
in Family Medicine
https://doi.org/10.5281/zenodo.14677252
Objective
: The use of bariatric surgery in patients with obesity and type 2 diabetes (T2DM)
has its own characteristics. This report describes the indications and contraindications for bariatric
surgery, including. specific - in the presence of T2DM. Various types of bariatric operations and
the mechanisms of their influence on carbohydrate and lipid metabolism are described. The results
of restrictive and bypass bariatric surgery in patients with obesity and T2DM are shown. The
requirements for bariatric operations are presented and the parameters for assessing their
effectiveness are presented, including. remission of T2DM after bariatric surgery. The causes of
postbariatric hypoglycemia, as well as the postoperative prognosis of the effectiveness of bariatric
surgery in relation to metabolic control in patients with obesity and T2DM, were analyzed.
Restrictive (gastro-restrictive) operations are aimed at reducing the volume of the stomach. During
restrictive operations, the stomach is divided into two parts, the volume of the upper part does not
exceed 15 ml. This can be achieved by vertical stapling of the stomach, leaving a narrow outlet
from its small part (vertical gastroplasty (VGP), Fig. 1a) or by using a special silicone cuff
(adjustable gastric band (AGB)). 1b). A more modern method - longitudinal (sleeve, vertical)
gastrectomy - involves removing most of the stomach, leaving a narrow tube with a volume of 60-
100 ml in its lesser curvature. The effect of malabsorptive (shunt) and combined operations is
based on shunting various parts of the small intestine, which reduces the absorption of food. When
bypassing the stomach, most of the duodenum and the initial part of the small intestine are removed
from the food passage, and with biliopancreatic bypass, almost the entire jejunum.
Materials and methods of research:
With BPS in the Hess-Marco modification
("Biliopancreatic diversion with duodenal bypass", i.e. BPS (diversion) with duodenal bypass), a
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pylorus-preserving PRG is performed, and the ileum is anastomotic not with the gastric cavity, but
with the initial part of the duodenum. The length of the intestine involved in the passage of food
is approximately 310-350 cm, of which 80-100 cm is allocated to the common loop, 230-250 cm
to the digestive loop (Fig. 2c). The advantages of this operation include preserving the pylorus and
thereby reducing the likelihood of dumping syndrome and peptic ulcer development in the area of
the duodenal anastomosis, which is also facilitated by a significant reduction in the number of
parietal cells when performing PRP. Recently, established ideas and stereotypes about T2DM in
obese patients have been revised. In particular, the claim that a significant loss of div weight
after bariatric surgery is the decisive factor in improving glycemic control in T2DM that developed
against the background of obesity has been refuted by the fact that a decrease in glycemia is
observed from the first day. a few weeks after surgery, i.e. long before a clinically significant
decrease in BW. With the widespread introduction of complex types of bariatric surgery (HS,
BPS), it has become clear that a decrease in BW is not the only factor determining the predictable
improvement in carbohydrate metabolism in obese people with T2DM.
Monitoring results:
Normalization of clinical and laboratory indicators in
T 2DM means
the absence of clinical symptoms of T2DM and the need for taking glucose-lowering drugs,
achieving fasting blood glucose levels <5.6 mmol/l, HbA1c <6%; Improvement of the course of
T2DM in such patients means the cessation of the need for glucose-lowering drugs and/or a
decrease in fasting glycemia from 5.6 to 6.9 mmol/l. Loss of MT by more than 15% of the original;
Achievement of HbA1c level ≤6%; Achievement of total cholesterol <4 mmol/l, low-density
lipoprotein cholesterol (LDL-C) <2 mmol/l, triglycerides <2.2 mmol/l; maintenance of blood
pressure (BP) <135/85 mmHg; Reduction of HbA1c level by more than 20% from baseline;
Achievement of LDL-C level <2.3 mmol/l; maintaining blood pressure <135/85 mm Hg.
According to the 2014 European Interdisciplinary Guidelines for Metabolic and Bariatric Surgery,
surgical treatment in the presence of T2DM is considered effective if: the HbA1c level has
decreased by more than 0.5% within 3 months or has reached a level of <7.0%; the postoperative
insulin dose has been reduced by 25% or more from the preoperative dose; the dose of oral
hypoglycemic drugs has been reduced by 50% or more from the preoperative dose. Criteria for
remission of T2DM after bariatric surgery; maintaining HbA1c level <6.5%; maintaining fasting
plasma glucose levels of 5.6-6.9 mmol / L (100-125 mg / dL) without pharmacotherapy for at least
1 year after surgery; maintaining HbA1c level <6%; maintaining fasting plasma glucose levels
<5.6 mmol/L (<100 mg/dL) without pharmacotherapy for at least 1 year after surgery;
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Conclusion
: Selective malabsorption of fats and complex carbohydrates due to the late
addition of bile and pancreatic enzymes to the digestive process, which helps to reduce the
concentration of free fatty acids in the portal vein system and, accordingly, reduce insulin
resistance, is the most important factor determining the improvement. T2DM; selective reduction
of ectopic lipid accumulation in skeletal muscle and liver, which improves insulin sensitivity (since
lipid overload in the liver in obesity is associated with a limited ability of adipose tissue to
accumulate lipids and increase its volume, which in turn leads to deposition of ectopic fat and
lipotoxicity, which creates the basis for dyslipidemia and insulin resistance in T2DM). The
experience of using bariatric surgery in obese patients with metabolic disorders and comorbidities
allowed Buchwald H. and Varko R. in 1978 to formulate the concept of “metabolic” surgery as a
section of bariatric surgery “as a surgical treatment of a normal organ or system to achieve a
biological result of improving health.” Subsequently, the many years of practice of using bariatric
surgery in patients with obesity and associated T2DM, the goal of which was initially to reduce
div weight, showed the serious potential of surgery in achieving compensation for T2DM that
developed against the background of obesity.
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