|Year : 2015 | Volume
| Issue : 1 | Page : 3-4
Dumping for type-2 diabetes
Edward Eaton Mason
Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
|Date of Web Publication||6-Jan-2015|
Edward Eaton Mason
Professor Emeritus, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mason EE. Dumping for type-2 diabetes. J Obes Metab Res 2015;2:3-4
In 1945, as a surgical intern at the University of Minnesota in Minneapolis, I was told that when performing a Billroth II gastrectomy, I should make the outlet of the stomach pouch small so as to decrease the rate of emptying, which causes dumping symptoms. These symptoms had been observed by fluoroscopy to coincide with swallowed (undiluted hypertonic) contents appearing in the distal small bowel within 5 min. In 1966, at the University of Iowa, I began 3 years of study in animals of gastric bypass for replacement of subtotal loop gastrectomy. My goal was to make loop gastrectomy simpler and reversible. After the 1-year, I was satisfied that gastric bypass would suppress acid secretion and would not cause stomal ulcers. I began two simultaneous studies of gastric bypass in (1) patients with duodenal ulcer and (2) morbidly obese patients. Gastric bypass did not relieve ulcer symptoms in seven patients but was effective in one patient who was heavy and lost weight. The morbidly obese patients lost weight.
Weight loss after loop gastrectomy was an unwanted complication for normal weight patients. I took advantage of this side effect using it where weight loss was needed. I did not anticipate the onset of two epidemics of obesity and type-2 diabetes. However, the surgical viewpoint has fulfilled my mentor, Wangensteen's recommendation of substituting scientific discipline for empiric craft.  Wangensteen wrote "May the spirit of inquiry, the love of learning, and appreciation of the History of Medicine create in our medical schools an intellectual atmosphere that will heighten greater medicine's commitment and accountability in the service to mankind." There began an interchange of experience by telephone and in 1977, I began an annual postgraduate course at the University of Iowa for surgeons who were treating obesity with intestinal and gastric bypass. In 1983, these meetings were incorporated in Iowa as The American Society for Bariatric Surgery. There were about 60 surgeons who attended, including a few from Scandinavia and Europe. The resolution of diabetes after intestinal and gastric bypass was discussed at the 1977 meeting and data from the University of Iowa were provided inbound copies of the presentations and discussions that were sent to attendees. We knew empirically that the gastric bypass resolved the diabetes immediately, but we did not know the mechanism.
In 1998 Nδslund et al. reported that small bowel peptides improved glucose metabolism for as long as 20 years after jejunoileal bypass for obesity.  This suggested to me that the common denominator between intestinal and gastric bypass was secretion of glucagon-like peptide-1 (GLP-1).  Strader called me about her desire to perform ileal transposition in rats. This showed the expected increase in plasma GLP-1.  Dumping must result in glucose reaching the distal bowel where it stimulates the secretion of GLP-1 and other hormones of distal L-cell.  I decided that if this was true, dumping must be a normal occurrence, or we would all have type-2 diabetes.
According to Brener et al. in 1983, gastric emptying begins with an initial gush that is regulated by the volume of gastric content.  Normal overflow of the duodenum provides samples of hypertonic content that is irritating to upper jejunum and is thus flushed to distal bowel where glucose, bile acid, and other stimulants of L-cell secretion cause release of GLP-1 into the portal circulation. Schirra et al. studied gastric emptying and incretin hormones after glucose ingestion in humans in 1996. 
When I began using gastric bypass for treatment of severe obesity, the disease was uncommon, and there was room on the operative schedule for such patients whenever needed. Now, because of the pandemics of severe obesity and its complication of type-2 diabetes, <1% of candidates for dumping type surgery can be scheduled. However, the dumping surgery showed that the oral administration of a hexose that is not absorbed could be used to treat type-2 diabetes. 
This was in 2008, but we have failed to provide enough data for approval of clinical use.
Sleeve gastrectomy is becoming more popular, but with increasing need for treatment of adolescents and children we need to preserve the stomach. Darido has shown that the invagination of the fundus with internal anastomosis to the antrum is an effective operation in rodents  and swine.  This needs clinical study now to obtain enough data for approval.
Fundic invagination could be called sleeve gastrotomy. It may help to resolve the epidemics of type-2 diabetes and severe obesity. Sleeve gastrotomy could be to sleeve gastrectomy what gastric bypass is to subtotal or total gastrectomy. Sleeve gastrotomy (fundic invagination) could preserve the distensible portion of the stomach for a lifetime in young people. Unfortunately, it takes years to obtain the desired follow-up, so approved long follow-up studies are urgent clinically and in the animal laboratory.
| References|| |
Wangensteen OH, Wangensteen SD. The Rise of Surgery from Empiric Craft to Scientific Discipline. Minneapolis: University of Minnesota Press; 1978.
Näslund E, Backman L, Holst JJ, Theodorsson E, Hellström PM. Importance of small bowel peptides for the improved glucose metabolism 20 years after jejunoileal bypass for obesity. Obes Surg 1998;8:253-60.
Mason EE. Ileal [correction of ilial] transposition and enteroglucagon/GLP-1 in obesity (and diabetic?) surgery. Obes Surg 1999;9:223-8.
Strader AD, Vahl TP, Jandacek RJ, Woods SC, D'Alessio DA, Seeley RJ. Weight loss through ileal transposition is accompanied by increased ileal hormone secretion and synthesis in rats. Am J Physiol Endocrinol Metab 2005;288:E447-53.
Mason EE. Dumping dependent diabetes: Surgical paradigm. Bariatr Times 2013;10:12.
Brener W, Hendrix TR, McHugh PR. Regulation of the gastric emptying of glucose. Gastroenterology 1983;85:76-82.
Schirra J, Katschinski M, Weidmann C, Schäfer T, Wank U, Arnold R, et al. Gastric emptying and release of incretin hormones after glucose ingestion in humans. J Clin Invest 1996;97:92-103.
Lu Y, Levin GV, Donner TW. Tagatose, a new antidiabetic and obesity control drug. Diabetes Obes Metab 2008;10:109-34.
Darido E, Moore JR. Comparison of gastric fundus invagination and gastric greater curvature plication for weight loss in a rat model of diet-induced obesity. Obes Surg 2014;24:897-902.
Darido E, Overby DW, Brownley KA, Farrell TM. Evaluation of gastric fundus invagination for weight loss in a porcine model. Obes Surg 2012;22:1293-7.