Metabolic surgery in diabetes

Post-surgery management

Clinical management of type 2 diabetes mellitus after bariatric surgery

A significant proportion of individuals undergoing bariatric surgery experience residual type 2 diabetes mellitus. This article outlines strategies for the clinical management of these patients.

Summary points

Three central mechanisms are purported to explain the effects of bariatric surgery on type 2 diabetes mellitus (T2DM):
- Caloric restriction
- Alterations in nutrient flow producing changes in gut hormone secretion.
- Reductions in lipotoxicity and changes in adipose tissue hormone secretion.
Factors that may be associated with non-remission and relapse of diabetes following bariatric surgery include older age, limited weight loss, insulin use and poor glycemic control prior to surgery, as well as longer duration of diabetes prior to surgery.
Management of T2DM following bariatric surgery may involve diet (nutritious low-carbohydrate, low fat and high-fiber diet) and increased physical activity, as well as medical therapy.
Recommended medical therapy includes the following:
- Metformin, thiazolidinediones (second-line after metformin), with sulfonylureas with metformin possibly useful to prevent further β-cell failure.
- Basal and prandial insulin if no response to insulin sensitizers or secretagogues.
- Incretin analogs.
- SGLT-2 inhibitors, particularly for those with weight regain.
- Phentermine-topiramate in those with weight regain or suboptimal weight loss.
- Orlistat for residual diabetes associated with inadequate weight loss or weight regain.
- Lorcaserin to promote or maintain adequate weight loss.
Available evidence suggests diabetes reoccurrence following bariatric surgery is due to either inadequate weight loss or to weight regain, combined with exhaustion of insulin-secreting pancreatic β-cells.
The authors propose pharmacologic intervention to reduce weight and increase insulin sensitivity, followed by treatments promoting insulin secretion if initial treatment is unsuccessful.

Khanna V, Kashyap SR. Curr Atheroscler Rep 2015; 17: 59. doi: 10.1007/s11883-015-0537-2

Nutritional management after bariatric surgery

This chapter outlines the dietary changes that are necessary following bariatric surgery, and discusses the importance of monitoring of nutritional status and supplementation for deficiencies to ensure optimal long-term outcomes.

Summary points

While associated with significant beneficial effects, bariatric surgery can also lead to several problems, including nutritional deficiencies, metabolic bone disease and renal stones.
Appropriate nutritional management post-surgery is vital, to monitor nutritional status, minimize complications and maximize weight loss.
A multiple phase diet following bariatric surgery is common, with a ‘normal’ diet often resuming after 6–8 weeks. Stages and timings vary by individual bariatric center, due to personal preferences of the surgeon and dietician.
In the long-term, all patients should be encouraged to follow a balanced, low-fat and low-sugar diet, with patients following recommended postoperative dietary advice having better weight-loss in the long term.
All patients should take a complete multivitamin and mineral supplement to minimize potential deficiencies.
Significant nutrients that should be monitored following surgery include protein, iron, vitamin B12 (one of the most common deficiencies following bariatric surgery), folate, thiamine, calcium and vitamin D, fat-soluble vitamins (A, E and K), zinc, copper and selenium.
Routine monitoring is imperative following bariatric surgery, with the dietician playing an important role in managing long-term outcome.

Pinnock GL. In: Obesity, bariatric and metabolic surgery: A practical guide. Edited by Agrawal S. Springer International Publishing, 2016. doi: 10.1007/978-3-319-04343-2_65

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