Impact of the different biliopancreatic limb length on diabetes and incretin hormone secretion following distal gastrectomy in gastric cancer patients

Abstract

The present study aimed to investigate changes in glucose metabolism and incretin hormone response following longer intestinal bypass reconstruction after distal gastrectomy (DG) in low BMI patients with gastric cancer and type 2 diabetes. A total of 20 patients were prospectively recruited and underwent either conventional Billroth I (BI), Billroth II with long-biliopancreatic limb (BII), or Roux-en-Y anastomosis with long-Roux limb (RY) after DG. A 75g-oral glucose tolerance test (OGTT) was given preoperatively; and at 5 days, 3 months, and 6 months postoperatively. Serum glucose, insulin, glucagon, glucagon-like peptide-1 (GLP-1), and glucose-dependent insulinotropic polypeptide (GIP) were serially measured. At 6 months after surgery, complete diabetes remission was achieved in 57.1% of the BII group but in no patients in the other two groups (p = 0.018). BII group showed a significant reduction in glucose concentration during OGTT at 6 months in contrast to the other 2 groups. In the BII group, a significant increase in GLP-1 secretion was observed after surgery but not maintained at 6 months, while postoperative hyperglucagonemia was alleviated along with a reduction in GIP. BII gastrojejunostomy with long biliopancreatic limb achieved better diabetes control with favorable incretin response after DG compared to BI or RY reconstruction.

Figure 1

Schematics of the each reconstruction type. (a) Billroth I, (b) long-limb Billroth II, and (c) long-limb Roux-en-Y reconstruction (BPL biliopancreatic limb, AL alimentary limb).

Figure 2

Flow diagram of the study progress (BMI body mass index, BI Billroth I, BII Billroth II, RY Roux-en-Y).

Figure 3

Changes in anthropometric data during the follow-up period after surgery (BMI body mass index, %TWL percentage of total weight loss, BI Billroth I, BII Billroth II, RY Roux-en-Y).

Figure 4

Diabetes status at 6 months after surgery.

Figure 5

(a) Dynamic changes of serum glucose level after oral glucose tolerance test (OGTT) in each group. (b) Area under curve (AUC) during OGTT (*p < 0.05; BI Billroth I, BII Billroth II, RY Roux-en-Y).

Figure 6

Dynamic changes and area under curve (AUC) during oral glucose tolerance test in (a) active glucagon-like peptide-1 (GLP-1), (b) glucose-dependent insulinotropic peptide (GIP), (c) insulin, and (d) glucagon (*p < 0.005 between the groups, ^†p < 0.005 compared to the baseline value; BI billroth I, BII Billroth II, RY Roux-en-Y).