Editors' ChoiceMetabolism

Biliopancreatic diversion is beyond just weight loss

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Science Translational Medicine  23 Oct 2019:
Vol. 11, Issue 515, eaaz3721
DOI: 10.1126/scitranslmed.aaz3721

Abstract

Biliopancreatic diversion slows glucose absorption and increases insulin sensitivity, which results in better glycemic control than other gastric bypass procedures.

Obesity and type 2 diabetes (T2D) have reached epidemic proportions worldwide. Accordingly, bariatric surgery is now an established option to combat both conditions. Multiple randomized controlled trials have demonstrated that bariatric surgery offers a sustainable glycemic control; higher remission rates of T2D; positive outcomes on hyperlipidemia and hypertension; and greater improvement in quality of life compared with medical therapy alone. Among the bariatric surgical procedures, Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure and has been shown to offer marked T2D remission rates. The less common and more complex procedure, biliopancreatic diversion (BPD), results in better glycemic control and higher rates of diabetes remission than RYGB; however, the underlying mechanism of this improvement is largely unknown.

Recent work by Harris et al. investigated the differences in several key factors that regulate glucose homeostasis in obese individuals without diabetes who underwent either BPD or RYGB. They first reported that upon mixed meal ingestion, the BPD group exhibited a slower rate of intestinal glucose absorption, which resulted in lower peak plasma glucose concentration and insulin secretion than those who achieved a similar percentage weight-loss after RYGB surgery. To investigate whole-body insulin sensitivity, they conducted hyperinsulinemic-euglycemic clamp studies and found that BPD resulted in greater insulin sensitivity than RYGB, without altering pancreatic β-cell function. Lastly, they measured certain plasma metabolites involved in glucose homeostasis and observed differences in anti-inflammatory eicosanoids and glucosamine concentrations in the BPD group, which likely contribute to the greater insulin sensitivity after BPD compared with RYGB.

Future randomized comparisons including patients with T2D are needed to validate these results and to further explore other potential differences between different bariatric surgical procedures. Although BPD is associated with higher risk of malnutrition and has a less favorable risk/benefit profile, this study highlights its superior antidiabetic mechanisms, which could be further exploited to develop novel alternative therapies for T2D management.

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