|Year : 2016 | Volume
| Issue : 1 | Page : 54-57
Does length of common limb influence remission of diabetes? Short-term results
Ramraj V Nagendra Gupta, Tulip Chamany, Ramesh Makam
Department of Minimal Invasive, Metabolic and Bariatric Surgery, Vikram Hospital, Miller's Road, Opp. St. Anne's College, Bangalore, Karnataka, India
|Date of Submission||16-Oct-2014|
|Date of Acceptance||01-Jan-2015|
|Date of Web Publication||17-Dec-2015|
Ramraj V Nagendra Gupta
#655, Burugal Mutt Road, VV Puram, Bangalore - 4, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Despite strict patient selection criteria, diabetes remission is not seen in all patients after gastric bypass. Can length of the common limb influence diabetes remission? Aim: To find if any correlation exists between the length of the common limb and remission of diabetes. Study Design: Prospective study. Materials and Methods: Twenty-five consecutive patients with Type II diabetes mellitus and a fasting C-peptide >1 ng/ml who underwent laparoscopic Roux-en-y gastric bypass were included. All patients had standard limb lengths and length of the common limb was measured in all patients. Patients were followed up and glycated haemoglobin (HbA1c) was repeated at 6 months postoperatively. Pre- and postoperative HbA1c were then correlated with the lengths of common limb to look for any relation. Statistical Analysis: Descriptive and inferential statistical analysis, analysis of variance (ANOVA). Results: Of the 25 patients, 15 were females and 10 were males. The mean age was 44.16 years and the mean body mass index (BMI) was 43.96 kg/m 2 . Preoperative HbA1c varied from 5.8 to 12.3%. Length of the common limb varied from 210 to 790 cm (mean 470.4 cm). HbA1c at 6 months ranged from 4.8 to 7.7% (mean 5.81%). On comparison of preoperative and 6 months postoperative HbA1c and correlating with the length of common limb, we found that patients with a common limb of length <600 cm had a statistically significant improvement in HbA1c compared to those with >600 cm length (P = 0.004). Conclusion: A shorter common limb does appear to have better chances of resolution of Type II diabetes mellitus in our study, thus paving the way for further studies.
Keywords: Common limb length, HbA1c, Roux-en-y gastric bypass, Type II diabetes mellitus
|How to cite this article:|
Nagendra Gupta RV, Chamany T, Makam R. Does length of common limb influence remission of diabetes? Short-term results. J Min Access Surg 2016;12:54-7
|How to cite this URL:|
Nagendra Gupta RV, Chamany T, Makam R. Does length of common limb influence remission of diabetes? Short-term results. J Min Access Surg [serial online] 2016 [cited 2020 Jan 22];12:54-7. Available from: http://www.journalofmas.com/text.asp?2016/12/1/54/152104
| ¤ Introduction|| |
Roux-en-Y gastric bypass is a time-tested bariatric procedure and is considered a gold standard in metabolic surgery.  Various modifications of this procedure including altering the length of the bilio-pancreatic and Roux limb have been tested to get the maximum benefit of surgery with minimal nutritional deficiencies.  In spite of strict patient selection norms including investigations to ensure a good pancreatic reserve and using the standard limb lengths for surgery, not all patients show remission of diabetes as expected. Apart from genetic factors, is there any other variable playing a role in diabetes remission? Length of the common limb appears to be one such variable for which researchers have not given much importance, especially in the light of a large variation in the lengths of the small bowel among individuals. Through this study, we wished to look for any correlation between the length of common limb and resolution of diabetes and the occurrence of dumping syndrome.
Aim of Study
Considering the wide variation in the lengths of small intestine, we wished to study in our centre if there is any correlation between the lengths of the common limb and the remission of Type II diabetes after Roux-en-Y gastric bypass.
| ¤ Materials and Methods|| |
A prospective study was conducted at Vikram and AV hospitals, Bangalore. A total of 25 consecutive patients aged between 30 and 65 years with Type II diabetes and a C-peptide level more than 1 ng/ml were included in the study from May 2013 to July 2014. The same team of surgeons was involved in both the centres. All patients were evaluated preoperatively including fasting and stimulated insulin and C-peptide levels, glycated haemoglobin (HbA1c), and nutritional assessment. Patients having fasting C-peptide above 1 ng/ml were selected for the study. All patients underwent the standard laparoscopic Roux-en-Y gastric bypass by six-port technique wherein a 30 ml gastric pouch was created by peri-gastric technique. A standard 150-cm-long Roux limb and a 60-cm-long bilio-pancreatic limb were created in all patients. Gastro-jejunostomy was done hand sewn in two layers and jejuno-jejunostomy with a white cartridge (2.5 mm) Endo GIA stapler. Enterotomy, mesenteric and Peterson's defects were closed hand sewn. Length of the common limb was measured in all patients prior to fashioning the jejuno-jejunostomy using an atraumatic bowel grasper with marking at 10 cm from the tip. Patients were followed up at 2 weeks and at 1, 3 and 6 months postoperatively. Random blood sugar levels and weights were documented at each visit and HbA1c was measured at 6 months postoperatively. The National Institutes of Health guidelines were used as the criteria for diabetes remission, i.e. HbA1c <6% considered as non-diabetic. ,,
Descriptive and inferential statistical analyses have been carried out in the present study. Results on continuous measurements are presented as mean ± SD (Min.-Max.) and on categorical measurements are presented as number (%). Significance is assessed at 5% level of significance. Analysis of variance (ANOVA) has been used to find the significance of study parameters between groups of patients. Student's t-test (two-tailed, dependent) has been used to find the significance of study parameters on a continuous scale within each group. The statistical software SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were used for the analysis of the data. ,,,
Significant figures: +Suggestive significance (P value: 0.05 < P < 0.10)
*Moderately significant (P value: 0.01 < P ≤ 0.05)
**Strongly significant (P value: P ≤ 0.01)
| ¤ Results|| |
Twenty-five consecutive patients with Type II diabetes mellitus were included in the study, of which 15 were females and 10 were males. Age varied from 27 to 63 years with a mean of 44.16 years and the mean body mass index (BMI) was 43.97 ± 9.45 kg/m 2 . Twenty-two patients had family history of diabetes with 10 of these patients having a stronger family history, i.e. more than two members being diabetic. Duration of diabetes varied from "newly detected" to 15 years. Preoperative HbA1c varied from 5.8 to 12.3% [Figure 1] and the C-peptide level varied from 1 to 6.6 ng/ml with a mean of 3.89 ± 1.29 ng/ml.
Length of the common limb, i.e. from jejuno-jejunostomy to ileo-caecal junction, varied from 210 to 790 cm, with the mean length being 470.40 ± 131.51 cm [Table 1].
HbA1c estimated at 6 months follow-up ranged from 4.8 to 7.7%, with a mean of 5.81% [Figure 2]. Two of our patients who had normal random blood sugar levels on monthly visits had a slightly raised HbA1c at 6 months compared to their pre-operative values.
On comparison of preoperative HbA1c with 6 months postoperative levels to look for diabetes remission and correlating these to the length of the common limb, it was found that patients with a common limb of length less than 600 cm had a statistically significant improvement in HbA1c compared to those with length more than 600 cm [Table 2], [Figure 3]. It was also observed that patients in the subset 501-600 cm long common limb had a strongly significant improvement. The "power" of the study calculated to eliminate the Type II error was 67% [Figure 4].
|Figure 3: Graph showing correlation between pre- and postoperative HbA1c with the limb length|
Click here to view
| ¤ Discussion|| |
The fact that Type II diabetes mellitus which constitutes 90-95% of diabetes in the world is an operable intestinal disease is now well accepted.  Despite bilio-pancreatic diversion inherent with its nutritional deficiencies and low patient satisfaction showing better remission of diabetes, Roux-en-y gastric bypass proposed by Mason and Ito in 1960 continues to be the favourite among metabolic surgeons around the world. ,, Understanding the incretin-anti-incretin effects seen has led to various modifications of Roux-en-y gastric bypass surgery in a quest to replicate its success with respect to diabetes remission. ,, Modifications include short (80-120 cm) and long (150-200 cm) Roux or alimentary limbs, short (50-75 cm) and long (100-200 cm) biliary limbs, distal gastric bypasses (150-200 cm from ileo-caecal junction) and mini gastric bypass. Stefanidis et al., in an evidence-based review, reported considerable variability in AL and BL length preferred by different bariatric centres, which ranged from 35 to 250 cm (average 110 cm) and from 10 to 250 cm (average 48 cm), respectively.  All modifications ensured a minimum of 150 cm of terminal ileum to avoid nutritional problems. Variations in the limb lengths were primarily designed based on patients' BMI, on intended weight loss and were not specific to resolution of comorbidities.  Higa et al., in their study, have shown no difference in weight loss between a 100 and 150 cm Roux limb and have also stated that increasing the bilio-pancreatic lengths to 100 cm is of no added benefit. The length of the Roux limb should be at least 75 cm, as lengths less than 60 cm can present with bile reflux and lengths more than 150 cm have not shown any added benefit in terms of long-term weight loss. 
Small intestine varies widely in its length from 4 to 10 m,  and this has largely been responsible for mushrooming of various modifications and for their successes and failures in gastric bypass surgery. The length of the small intestine excluding the duodenum varied from 325 to 650 cm with an average of 470 cm in a study by Lulasz Kaska et al. that involved 93 patients and a mean of 671.4 ± 115.7 cm (434-990 cm) in the study of Savassi-Rocha et al.  In our study group, the length varied from 410 to 1000 cm.
Literature search shows that most of the studies concentrate on bilio-pancreatic and alimentary limb lengths to report the success of weight loss and there are hardly any studies correlating limb lengths to remission of diabetes. Only a handful of these studies focus upon the length of common limb in the context of resolution of diabetes. We believe that the length of the common limb could be an important factor in the resolution of diabetes, especially in the light of recent research pointing to the role of bile acid activation, farnesoid X receptor (FXR) and the membrane receptor G-protein-coupled bile acid receptor 5 (TGR5) in diabetes resolution. ,
Twenty-four of 25 patients in our study had HbA1c more than 6%, indicating a poor control of diabetes. All of them had a C-peptide level >1 ng/ml and were candidates for metabolic surgery. The length of the common limb was measured prior to jejuno-jejunostomy in all patients, and the average common limb length was 470.40 ± 131.51 cm. Savassi-Rocha et al. noted a common limb length of 505.3 ± 113.3 cm (268-829 cm) after a 110 cm Roux limb.  We had no early postoperative complications. All patients except two had reached laboratory remission of diabetes in hospital, i.e. FBS less than 100 mg%; both were discharged on single dose of oral hypoglycaemic which was stopped at the second month follow-up. At 6 months of follow-up, all were euglycaemic, which corroborates well with the finding of Lulasz Kaska et al.
On correlating the lengths of common limb with resolution of diabetes, we found a statistically significant resolution of diabetes in patients with length lesser than 600 cm, i.e. shorter lengths had better resolution. These results were similar to those of Lulasz Kaska et al. who, in their comparative study of short and long bilio-pancreatic limb, observed a more significant improvement in laboratory diabetic markers with shorter common limb. An interesting finding was patients in subsets with common limb of lengths 501-600 cm and <400 cm had significantly better resolution than those in the 401-500 cm group. Of the seven patients in 401-500 cm group, two had strong family history, four had a weak history, one had no family history, and all but one patient had C-peptide >3 ng/ml.
All our patients were started on calcium and vitamin supplements from the second week onwards and none had any signs or symptoms of vitamin or mineral deficiency. Two of our patients reported early dumping in the first month which was relieved with dietary modifications.
The fact that shorter common limb results in lesser absorption and better weight loss is well known, but this translating into better sugar control irrespective of significant weight loss implicates the possible exaggerated role of incretins, anti-incretins, bile acid stimulation of FXR and TGR5 receptors in these patients.
The limitation to our study was the smaller number of patients and the shorter duration of follow-up which explains the elicited "power" of the study. Further follow-up is required to clearly establish this correlation. Establishing this correlation will help in modifying our bypasses by way of altering the limb lengths, ensuring a shorter common limb and getting maximum benefit from the surgery.
| ¤ Conclusion|| |
A shorter common limb appeared to have a better resolution of Type II diabetes mellitus in our short prospective observational study, which paves the way for conducting larger studies with longer follow-up.
| ¤ References|| |
Hussain A, Mahmood H, El-Hasani S. Can Roux-en-Y gastric bypass provide a lifelong solution for diabetes mellitus? Can J Surg 2009;52:E269-75.
Stefanidis D, Kuwada TS, Gersin KS. The importance of the length of the limbs for gastric bypass - an evidence-based review. Obes Surg 2011;21:119-24.
World Health Organization. Geneva: WHO Diabetes Unit; 2011. Health experts accept use of HbA1c for diagnosing diabetes. Available from: http://www.who.int/diabetes
. [Last accessed on 2014 Aug].
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2009;32:62-6.
Buse JB, Caprio S, Cefalu WT, Ceriello A, Del Prato S, Inzucchi SE, et al
. How do we define cure of diabetes? Diabetes Care 2009;32:2133-5.
Rosner B. Fundamentals of Biostatistics. 5 th
ed. Duxbury Press, Pacific Grove, California; 2000. p. 80-240.
Riffenburg RH. Statistics in Medicine. 2 nd
ed. United States: Academic Press; 2005. p. 85-125.
Rao PSS, Richard J. An Introduction to Biostatistics, A manual for students in health sciences. New Delhi: Prentice hall of India; 4 th
ed. 2006. p. 86-160
Suresh K, Chandrashekara S. Sample Size estimation and Power analysis for Clinical research studies. J Hum Reprod Sci 2012;5:7-13.
Rubino F. Is type 2 diabetes operable intestinal disease? Diabetes Care 2008;31(Suppl 2):290-6.
Scopinaro N. Thirty-five years of BPD: notes on gastrointestinal physiology to complete the published information useful for better understanding and clinical use of the operation. Obes Surg 2012;22:427-32.
Prachand VN, Ward M, Alverdy JC. Duodenal switch provides superior resolution of metabolic comorbidities independent of weight loss the super obese (BMI (50 kg/m 2
) compared to gastric bypass. J Gastrointest Surg 2010;14:211-20.
Thaler JP, Cummings DE. Hormonal and metabolic mechanisms of diabetes remission after gastrointestinal surgery. Endocrinology 2009;150:2518-25.
Dar MS, Chapman WH, Pender JR, Drake AJ 3 rd
, O′Brien K, Tanenberg RJ, et al
. GLP-1 response to a mixed meal: What happens 10 years after Roux-en-Y gastric bypass? Obes Surg 2012;22:1077-83.
Pattou F, Beraud G, Arnalsteen L, Seguy D, Pigny P, Fermont C, et al
. Restoration of beta cell function after bariatric surgery in type 2 diabetic patients: A prospective controlled study comparing gastric banding and gastric bypass. Obes Surg 2007;17:1041-3.
Hernandez-Martinez J, Calvo-Ros MA. Gastric by-pass with fixed 230 cm long common limb and variable alimentary and biliopancreatic limbs in morbid obesity. Obes Surg 2011;21:1879-86.
Higa KD. Laparoscopic gastric bypass: Technique and outcomes. In: Nguyen NT, Blackstone RP, Morton JM, Ponce J, Rosenthal RJ, editors. The ASMBS Textbook of Bariatric Surgery-Vol. 1. Bariatric surgery. New York: Springer Science+Business Media; 2015. p. 183-92.
Savassi-Rocha AL, Diniz MT, Savassi-Rocha PR, Ferreira JT, Rodrigues de Almeida Sanches S, Diniz Mde F, et al
. Influence of jejunoileal and common limb length on weight loss following Roux-en-Y gastric bypass. Obes Surg 2008;18:1364-8.
Kaska L, Kobiela J, Proczko M, Stefaniak T, Sledzin´ski Z. Does the length of the biliary limb influence medium-term laboratory remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass in morbidly obese patients? Wideochir Inne Tech Malo Inwazyjne 2014;9:31-9.
Ma H, Patti ME. Bile acids, Obesity, and the metabolic syndrome. Best Pract Res Clin Gastroenterol 2014;28:573-83.
Sonne DP, Hansen M, Knop FK. Bile acid sequestrants in type 2 diabetes: Potential effects on GLP1 secretion. Eur J Endocrinol 2014;171:R47-65.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]