Surgical Treatment of Non-obese Type 2 Diabetic Patients With Duodenal Exclusion
Surgical Treatment of Non-obese Type 2 Diabetic Patients With Duodenal Exclusion
Diabetes reversion is observed after bariatric surgeries even before significant weight loss
 could explain it, mainly in predominantly malabsorptive procedures (98,9% for biliopancreatic
 diversion or duodenal switch), followed by those combining malabsorption and gastric
 restriction (83,7% for Roux-en-Y gastric bypass). Changes in the hormonal communication
 between the digestive system and the pancreas would explain the antidiabetogenic role of the
 surgery, so this effect could be obtained in nonobese, diabetic individuals.

 In order to try this hypothesis, RUBINO and MARESCAUX (2004) studied the gastrojejunal bypass
 (duodenal exclusion)in an mouse model of diabetes without obesity. In their technique the
 stomach volume is kept intact, maintaining the caloric ingestion and the weight of the
 animals. There was a fast improvement of diabetes, independent of diet and weight, without
 the potential nutritional deprivations commonly seen in the bariatric surgery like iron and
 vitamin deficiency.

 This study will evaluate the mechanisms of amelioration of type 2 diabetes mellitus after
 duodenal exclusion surgery in human non-obese, diabetic volunteers and known insulin
 secretion capacity, by the method of standardized meal stimulus. It is expected to be
 secondary to changes in the gastrointestinal hormones that stimulate insulin secretion
 (incretins).

 The knowledge about the clinical outcomes of this technique in humans and the description of
 the secretion pattern of gastrointestinal hormones after the surgery may contribute to the
 implementation of this surgery as a new therapeutic option for overweight (non-obese)
 diabetic patients.
There is large recovery of insulin sensibility after bariatric surgery, as the patients get
 closer to ideal weight. Diabetes reversion is more frequent after predominantly malabsorptive
 procedures (98,9% for biliopancreatic diversion or duodenal switch), followed by those
 combining malabsorption and gastric restriction (83,7% for Roux-en-Y gastric bypass).
 Glycemia normalization occurs in an early phase of the postoperative period, even before
 significant weight loss could explain it. These techniques have in common a bypass of the
 duodenum and part of the jejunum. Many peptides are released in this segments that regulate
 pancreatic beta cells (insulin producers) either in physiological state or in diabetes.
 Anatomical-functional changes in the enteroinsular axis would explain the antidiabetogenic
 role of the surgery, so this effect could be obtained in nonobese, diabetic individuals.

 In order to try this hypothesis, RUBINO and MARESCAUX (2004) studied the gastrojejunal bypass
 (duodenal exclusion)in Goto-Kakizaki mice (GK), the most used animal model of diabetes
 without obesity. In their technique the stomach volume is kept intact, maintaining the
 caloric ingestion and the weight of the animals. There was a fast improvement of diabetes,
 independent of diet and weight. The authors concluded that this procedure should be applied
 in humans for reversal of diabetes without the potential nutritional deprivations commonly
 seen in the bariatric surgery like iron and vitamin deficiency.

 The amelioration of diabetes after bariatric surgery is related to the modulation of
 production of gastrointestinal hormones relevant to the insulin production (incretin effect).

 This study will evaluate the mechanisms of amelioration of type 2 diabetes mellitus after
 duodenal exclusion surgery in human non-obese, diabetic volunteers and known insulin
 secretion capacity, by the method of standardized meal stimulus. It is expected to be
 secondary to changes in the gastrointestinal hormones that stimulate insulin secretion
 (incretins).

 The knowledge about the clinical outcomes of this technique in humans and the description of
 the secretion pattern of gastrointestinal hormones after the surgery may contribute to the
 implementation of this surgery as a new therapeutic option for overweight (non-obese)
 diabetic patients.
Inclusion Criteria:

 -  Age: 18 to 60 years.

 -  BMI between 25 and 29,9 kg/m².

 -  Weight variance less than 5% in the last 3 months.

 -  Previous diagnosis of diabetes type 2.

 -  Insulin requirement, alone or along with oral agents

 -  Capacity to understand the procedures of the study.

 -  To agree voluntarily to participate of the study, signing an informed consent.

 Exclusion Criteria:

 -  Positive Anti-GAD antibodies

 -  Laboratorial signal of probable failure of insulin production, i. e., seric peptide C
 lesser than 1 ng/mL.

 -  History of hepatic disease like cirrhosis or chronic active hepatitis.

 -  Kidney dysfunction (creatinine > 1,4 mg/dl in women and > 1,5 mg/dl in men).

 -  Hepatic dysfunction: ALT and/or AST 3x above upper normal limit.

 -  Recent history of neoplasia (< 5 years).

 -  Use of oral or injectable corticosteroids for more than consecutive 14 days in the
 last three months.