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Ileal interposition

A review of Ileal interposition surgery for T2DM

Diagrammatic representation of ileal interposition with diverted sleeve gastrectomy
Long-term studies are needed to confirm the findings and potential side effects on a larger number of patients

Ileal Interposition in combination with Sleeve Gastrectomy (IISG) and Diverted Sleeve Gastrectomy (IIDSG) is known to improve glycemic control and lead to a significant reduction in oral hypoglycemic agents (OHAs) and insulin therapy. However, although the results from various studies have shown the safety, feasibility, and efficacy of the surgical procedure for the treatment of T2DM, researchers from Tehran University of Medical Sciences, Tehran, Iran, writing the in Journal of Diabetes & Metabolic Disorders, said that the procedure is not recommended for general use and long-term studies are needed to confirm the findings and potential side effects on a larger number of patients.

In their paper, ‘Ileal interposition surgery for treatment of type 2 diabetes mellitus-pros and cons’, the researchers reviewed several papers that have assessed Ileal Interposition (II), Ileal Interposition in combination with sleeve gastrectomy (IISG) and diverted sleeve gastrectomy (IIDSG). “These procedures,” they state, “are not limited to remission of T2DM, but hypertension, hyperlipidaemia, obesity, and obstructive sleep apnoea.”

They begin by stating that Ileal Interposition can be used for obese and non-obese patients to treat diseases that target the metabolic syndrome, and uses both foregut (excluding of the duodenum) and hindgut mechanisms. Several studies have shown that these types of surgical procedures can improve glycaemic control, (including reductions in HbA1c, fasting blood glucose (FBG), postprandial glucose (PPG)) and also may improve the metabolic parameters, and are maintain out to three years.

Weight loss via Ileal Interposition is a result of increased release of peptides secreted in the ileum, GLP-1 and peptide YY (PYY), which has anorectic effects. They authors explain that “the ileal interposition procedure, earlier exposure of food to ileum and rapid stimulation of the interposed ileal segment by ingested food leads to augmented glucagon-like peptide 1 (GLP-1) secretion. GLP-1 resulted in delaying gastric emptying, promotes satiety, suppressing appetite, inhibiting glucagon secretion, decreasing gluconeogenesis, and stimulating the glycogenesis.”

In addition, ghrelin is known to stimulate the secretion of hyperglycaemic hormones such as glucagon, cortisol and growth hormone and also inhibit insulin secretion. In the SG component of the IISG and IIDSG procedures, serum level of ghrelin is reduced and patients feel satiety and restrict their caloric intake.

The researchers state that unlike other bariatric procedures, Ileal Interposition is a procedure that does not lead to malabsorption. For example, in an IIDSG procedure, duodenum and part of the jejunum are bypassed and can cause malabsorption, and therefore patients are recommended to take iron, calcium, B12, and multivitamins supplementation regularly.

However, some studies have reported minor and early postoperative complications including vomiting, oesophagitis, bowel obstruction, gout and urinary tract infection, although no major long-term surgical complications have been reported. However, they note that in advanced T2DM, iatrogenic hypoglycaemia can be a limiting factor for these procedures.

In a study published by Ugale et al. introduced the Diabetes Remission Score (DRS) for choosing the type of surgery and predicting diabetes remission following IISG or IIDSG. The DRS included three grades as grade 1 (mild, DRS 7–8), grade 2 (moderate, 9–11) and grade 3 (severe, DRS 12–14), with higher scores associated with lower chance of remission.

“In conclusion, the results of various studies have shown the safety, feasibility, and efficacy of the surgical procedure for the treatment of T2DM,” they conclude. “Although it is an effective treatment option, this procedure is not recommended for general use and long-term studies are needed to confirm these findings and potential side effects on a larger number of patients.”

To access this paper, please click here

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