INTRODUCTION:

Obesity is a hypercaloric state related with an expanded danger of creating type 2 diabetes mellitus (T2DM) and cardiovascular diseases¹. Obesity, and specifically morbid obesity (characterized as a body mass index BMI > 40 kg/m2), prompts a high occurrence of complexities and a diminishing in future, particularly among more youthful adults². The Iraqi society is stacked with obesity and its extending ordinariness and also extraordinary countries around the globe. Obesity is not a malady of known cause, but rather a few elements are included in its development.

Genetic elements, inner emissions, mental variables and ecological components assume imperative parts in creating weight. Imbalance of energy is the most imperative consider weight pick up and obesity³. There is solid confirmation that bariatric surgery can effectively treat most patients with morbid stoutness, and it is the main prescribed successful treatment for morbid obesity^4-6.

Bariatric surgery is presently a typical method around the world. It adequately brings down body weight and resolves obesity related complexities, and is better than different methods for weight loss⁷. Uncommonly, for obesity individuals in prediabetes condition, weight control could bring down the danger or postpone the onset of T2DM, with strict calorie confinement notwithstanding turning around the movement of T2DM in set up patients⁸. Progressive, a few bariatric surgeries exist. Laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrostomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the three most usually utilized bariatric surgeries and LRYGB, went with more fast and more significant weight reduction than " restrictive " strategy (LAGB) and less danger of disappointment or intricacy than the "malabsorptive" method (LSG), is for the most part considered as the " gold standard " procedure⁹. Laparoscopic mini-gastric bypass (MGB), initially revealed by Rutledge, was proposed as a straightforward and successful treatment of morbid obesity¹⁰. A few clear points of interest of the MGB contrasted and the best quality level LRYGB are single anastomosis, shorter expectation to absorb information, less inner imperfections for herniation and simplicity of modification or inversion. In the meantime, concerns identifying with the symptomatic biliary reflux and the danger of gastric/esophageal tumor have kept its across the board adoption¹¹. The aim of this study was to prospectively evaluate the glucose, HbA₁c and lipid profile before MGB and at 4 & 6 months of follow-up in Iraq.

Subjects and Methods:

The study was conducted on 30 morbid obese patients (18 female, 12 male) who presented for MGB in Najaf, Iraq during the period from July 2016 until the end of February 2017.

The patients were 18 women and 12 men, ranging from 22-55 years of age (mean age 34.83± 7.5 years).

A questionnaire was intended to get the data of the patient which included name, age, gender, height (m), and weight (Kg), before and then afterward the bariatric methodology, date of technique, complications and other diseases, for example, (hypertension, diabetes mellitus and cardiovascular disease), estimation of BMI (Kg/m²), Fasting blood glucose FBG (mg/dl), Glycated Hemoglobin (HbA₁c%), cholesterol (mg/dl), Tri glyceride (TG) and high-density lipoprotein (HDL) (mg/dl) were recorded at baseline, 2 and 6 months from the baseline.

A portion of the patients were under a routine of one of a kind eating routine before bariatric procedure to get a change of nourishment admission affinities which the patients should trail after the techniques.

All patients experienced complete assessment during follow-up, including medications, dietary behavior, anthropometric and clinical parameters, and blood sampling for glucose, HbA₁c and lipid profile. Excess body mass index loss percent (% EBL) is now being adopted as the standard measure for studies of many granting bodies. (%EBL = (preoperative BMI – current BMI) / (preoperative BMI – 25) x 100)% EBL uses BMI 25 as the upper limit of normal ¹². The change in body weight (%WL) was calculated as preoperative body weight minus postoperative body weight, divided by preoperative body weight, times 100.

Collection of blood samples:

Five milliliters of venous blood samples were drown using a disposable needle and plastic syringes from each subject. Blood was left at room temperature for 10 minutes to clot, centrifuged 6000 rpm for 10 minutes, and then serum was separated and transported into new disposable tubes.

Statistical Analysis:

Descriptive information were communicated as mean±SD. Baseline and result factors were compared with paired T test. A p value of <0.05 was utilized to express significant statistical difference. The PC programming utilized for examination was SPSS 20.0

RESULTS:

Table 1 demonstrates three measurements for patients (n=30) , the first measurement was before MGB procedure (base line characteristics) ,while second measurement was two months after MGB and the third reading was six months after LRYGB procedure with the mean ± SD of all Parameters.

Table 1: Mean ± SD of parameters in patients prior to LRYGB and p-value between pre-operative and 2 and 6 months post-operative.

Parameters	Pre-operative base line	Two months post-operative	Six months post-operative
Body weight (kg)	135.36 ± 18.4	119.6 ± 17.8*	88.1 ± 15.4*
BMI (kg/m²)	51.7 ± 7.1	44.26 ± 4.025*	31.10 ± 1.72*
EBL %	--	29.96 ± 11.8	74.62 ± 14.04
FBG (mg/dl)	106.4 ± 15.2	87 ± 10.5*	84.83 ± 4.6*
HbA₁c %	6.20 ± 0.42	5.93 ± 0.39*	5.55 ± 0.37*
Cholesterol(mg/dl)	135.36 ± 29.9	176.3 ± 28.5*	162.63 ± 26.5*
TG (mg/dl)	138.46 ± 48.8	127.83± 38.26*	110.96 ± 30.5*
HDL (mg/dl)	32.3 ± 7.87	34.76 ± 6.63*	40.73 ± 8.8*
LDL (mg/dl)	127.05 ± 32.1	116.04 ± 30.8*	99.85 ± 30.1*
VLDL (mg/dl)	27.68 ± 9.76	25.52 ± 7.67*	22.04 ± 6.28*

*Significant difference (p< 0.001).

BMI: Body mass index. EBL: Excess body mass index loss. FBG: Fasting blood glucose. HbA₁c: Glycated hemoglobin. TG: Triglyceride. HDL: High-density lipoprotein. LDL: Low-density lipoprotein. VLDL: Very low-density lipoprotein.

Anthropometric characteristics:

It can be noticed from table 1 that the mean values of each of body weight (119.6 ± 17.8 kg) and BMI (44.26 ± 4.025 kg/m²) and were significantly declined after two months of MGB (p<0.001) compared with that of preoperative means (135.36 ± 18.4 kg and 51.7 ± 7.1 kg/m² respectively), also there are declined in the mean ± SD of these parameters after six months of this procedure (88.1 ± 15.4 kg and 31.10 ± 1.72 kg/m² respectively) with a significant difference (p<0.001).

There are increasing in the mean of EBL% during 2 and 6 months post-operative (29.96 ± 11.8 and 74.62 ± 14.04) according to continuous dropping in the BMI and weight.

FBG and HbA₁c:

After two months of MGB, mean FBG (87 ± 10.5 mg/dl) was significantly declined (p=0.001) compared with pre-operative mean value (106.4 ± 15.2 mg/dl) also there was a significant decrease (p= <0.001) noticed in mean level of HbA₁c (5.93 ± 0.39 %) compared with pre-operative mean value (6.20 ± 0.42 %). Six months post-operative showed declining mean in both of FBG (84.83 ± 4.6 mg/dl) and HbA1c (5.55 ± 0.37 %) with p-value <0.001, as presented in Figures 1 & 2.

Figure (1): FBG levels in patients pre MGB and 2 & 6 months post-operative.

Figure (2): HbA₁c levels in patients pre MGB and 2 & 6 months post-operative.

Lipid profile:

Each of total cholesterol, TG, LDL and VLDL were showed a significant decreasing (p= <0.001) in their mean value (176.3 ± 28.5, 127.83± 38.26, 116.04 ± 30.8 and 25.52 ± 7.67 mg/dl respectively) after two months of MGB compared with pre-operative means (135.36 ± 29.9, 138.46 ± 48.8, 127.05 ± 32.1 and 27.68 ± 9.76 mg/dl respectively), also there are a significant decreasing (p= <0.001) in their means (162.63 ± 26.5, 110.96 ± 30.5, 99.85 ± 30.1 and 22.04 ± 6.28 mg/dl respectively) after six months compared with pre-operative means (see figure 3).

The mean value of serum HDL after two months (34.76 ± 6.63 mg/dl) and after six months (40.73 ± 8.8 mg/dl) of MGB was significantly increased (p= <0.001) compared with pre-operative mean value (32.3 ± 7.87 mg/dl).

Figure (3): Serum cholesterol, triglyceride, LDL & VLDL levels in patients pre MGB and 2 & 6 months post-operative.

DISCUSSION:

Regardless of a huge number of distributed cases now accessible in the logical writing, MGB keeps on being a questionable method and is once in a while held to a more elevated amount of logical investigation than numerous other bariatric procedures¹³. Mini gastric surgery is in effect progressively performed to control morbid weight and T2DM¹⁴. In spite of the fact that LRYGB is viewed as the highest quality level of bariatric surgery for a long time, MGB, a generally new change of circle gastric sidestep initially portrayed by Rutledge in 2001¹⁵, is mainstream in a few focuses because of various advantages, for example, shorter agent times, less demanding system, and great weight reduction results^15,16. Thinks about have demonstrated that MGB was successful for the treatment of obesity and good outcomes in the expulsion of T2DM in patients with obesity^17,18 and prompt enhance the personal satisfaction in these patients³.

Excessive weight loss in mini gastric bypass after follow-up in this study was similar to other published studies^3,19. In another study in 2015 on 86 patients under mini gastric bypass surgery results showed that patients had 92.4-minute surgery and postoperative hospital stay 2.2 days. There were no complications after surgery and weight loss At 6 months follow-up after surgery was 27.5 %total body weight loss and 60.1% excess body weight loss was seen¹³.

The consideration of gender shows that female had greater percent weight loss than male after 6 months of follow-up, as seen in Figure(4). This result is compatible with Karen et al., study which found that women had greater %WL than men during 3 years follow-up periods ²⁰.

Figure (4): %WL by gender (male & female) in MGB at 6 months post operation.

In this review, it was found that patients demonstrated stamped change in their diabetic status. Roughly all of members demonstrated finish reduction of diabetic mellitus amid follow-up as per the dropping in each of FBG and HbA₁c.

Lee, in 2011, examined the metabolic part of MGB in a randomized controlled trial (RCT) including 60 tolerably obese diabetic patients²¹. The outcomes demonstrated a higher adequacy of MGB versus LSG both as far as weight reduction and T2DM abatement. These outcomes are affirmed in another multicenter Asian report in 2012 on 200 modestly obese patients²². People who experienced gastric bypass strategies (gastric bypass or mini-gastric bypass) lost more weight and came to a higher T2DM reduction rate at 1 year, contrasted with patients treated by restrictive methods (sleeve gastrostomy or gastric banding).

The viability of MGB in giving diabetes lessening is affirmed in long haul examines also. Lee reports a significantly bring down level of HbA₁c at 5 years in patients who experienced MGB against sleeve gastrostomy in a RCT²³, while Guenzi detailed 82.5 % of diabetes control with HbA₁c lower than 6.5 %, after a mean follow-up of 26 months, taking after MGB²⁴.

This methodical review and meta-investigation of Yingjun Quan et al. thoroughly assessed the safety and viability of MGB and contrasted it and sleeve gastrostomy, gastric banding, and gastric bypass. MGB appeared to be effective in lessening weight and enhancing T2DM with generally low morbidity and mortality⁸.

In the recent review by Schauer et al., specialists gave the in‑depth assessment of the clinical result in 240 diabetic excessively fat bariatric patients with a follow‑up rate of 80%. The creators noticed that after surgery, Fasting plasma glucose and HbA₁c focuses came back to typical levels (in 83%) or especially enhanced in all patients. A significant decrease being used of oral antidiabetic specialists (80%) and insulin (79%) took after surgical treatment was observed²⁵.

Dyslipidemia is basic element in fat patient and real hazard consider for improvement of atherosclerosis and afterward heart related diseases²⁶. Bariatric surgery has ended up being a compelling treatment against fat related comorbidities accomplishing high rate of reduction in sickness, for example, T2DM²⁷ or hypertension²⁸ among others. In these instances of dyslipidemia studies have indicated adequate here and now result after bariatric surgery achieving over 85% of determination in one year²⁹.

Caughton. It is not irrelevant that the change of lipid profile could be auxiliary to wholesome example control and to weight reduction extent. The aftereffects of the present review demonstrate a reduction in all out cholesterol, TG, and LDL and increment in HDL. These adjustments in a comparable review performed by Nguyen et al. on 95 beefy beyond belief patients were experienced bypass procedure³⁰. Comparable outcomes were acquired by Karamollah et al. with a critical change of lipid profile taking after bypass procedure³¹. A significant change of HDL has been given by different creators after MGB^32,33.

In conclusion this review demonstrates that MGB is great bariatric technique with amazing outcomes on 6-months follow up in regards to body weight lessening, BMI. Six month after strategy enhance glucose homeostasis and lipid profile were joined by reduction in FBG, HbA₁c, Total Cholesterol, TG and LDL and increment in HDL cholesterol change in significant way. The short term follow up period after the method and the moderately low no. of patients incorporated into the review were potential impediments of this review. Be that as it may, results are practically identical to other as of late distributed reviews.

REFERENCES:

1. Camilla H.; Britt E.; Margareta O.; Lars L.; Magnus S.; Andres K. (2003). Ghrelin and Adipose Tissue Regulatory Peptides: Effect of Gastric Bypass Surgery in Obese Humans. The Journal of Clinical Endocrinology & Metabolism, 88(7):3177–3183.

2. Fontaine K.R.; Redden D.T.; Wang C.;et al.(2003). Years of life lost due to obesity. JAMA., 289:187–193.

3. Abdolreza P.; Sima Karbalaei E. (2016). Excessive Weight Loss Following Laparoscopic Gastric Mini Bypass or Roux-En-Y Gastric Bypass Surgery. International Journal of Clinical Medicine, 7, 445-449.

4. NIH conference (1991). Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med, 115:956-961.

5. Pories W.J.; Swanson M.S,; MacDonald K.G.; Long S.B.; Morris P.G.; Brown B.M.et al.(1995). Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg, 222:339-350; discussion 350-352.

6. O’Brien P.E.; Dixon J.B.; Laurie C.; Skinner S.; Proietto J.; McNeil J.et al. (2006). Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med, 144:625-633.

7. Mohammad Ali K. M.; Maryam B.; Mohammadreza E.; Reza E.; Alireza K. (2017). Severe Fatal Protein Malnutrition and Liver Failure in A Morbidly Obese Patient After Mini-Gastric Bypass Surgery. International Journal of Surgery Case Reports, S2210-2612(17)30105-0.

8. Yingjun Q.; Ao H.; Min Y.; Ming X.; Biao Z.; Peng Z.; Bo Y.; Zhijun M. (2015). Efficacy of Laparoscopic Mini Gastric Bypass for Obesity and Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis. Gastroenterology Research and Practice, 13.

9. Marmuse J. P. and Parenti L. R. (2010). Gastric bypass. Principles, complications, and results. Journal of Visceral Surgery, 147, no. 5: 31–37.

10. Wei-Jei L.; Po-Jui Y.; Weu W.; Tai-Chi C.; Po-Li W.; Ming-Te H. (2005). Laparoscopic Roux-en-Y Versus Mini-Gastric Bypass for the Treatment of Morbid Obesity A Prospective Randomized Controlled Clinical Trial. Ann Surg, 242: 20–28.

11. Johnson W.H.; Fernanadez A.Z.; Farrell T.M. (2007). Surgical revision of loop (‘mini’) gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass. Surg Obes Relat Dis, 3: 37–41.

12. Kuczmarski R.J. and Flegal K.M. (2000). Criteria for definition of overweight in transition. Background and recommendations for the United States. Am J Clin Nutr, 72: 1074-81.

13. Parmar C. D.; Mahawar K. K.; Boyle M.; Carr W. R.; Jennings N.; Schroeder N.; Balupuri S.; Small P. K. (2016). Mini Gastric Bypass: first report of 125 consecutive cases from United Kingdom. Clinical Obesity, 6:61–67.

14. Hyun J.; Seong Sook H.; Jiyoung H.; Kyung Y. (2015). Mini-Gastric Bypass to Control Morbid Obesity and Diabetes Mellitus: What Radiologists Need to Know. Korean J Radiol, 16(2):325-333.

15. Rutledge R. (2001). The mini-gastric bypass: experience with the first 1,274 cases. Obesity surgery, 11(3):276-80.

16. Rutledge R. and Walsh T.R. (2005). Continued excellent results with the mini-gastric bypass: sixyear study in 2,410 patients. Obesity surgery, 15(9):1304-8.

17. Hu X.G., et al. (2009). Short-Term Outcome of Laparoscopic Gastric Bypass and Minigastric Bypass on Obesity Patients with Type 2 Diabetes Mellitus. Zhonghua Wei Chang WaiKeZaZhi, 12, 554-557.

18. Lee W.J. et al. (2012). Laparoscopic Roux-en-Y vs. Mini-Gastric Bypass for the Treatment of Morbid Obesity. A 10-Year Experience. Obesity Surgery, 22, 1827-1834.

19. Collins, B.J. et al. (2007). Gastric Bypass: Why Roux-en-Y? A Review of Experimental Data. Arch Surg, 142, 1000-1003; discussion 1004.

20. Karen J.; Yii-Chieh H.; Fadi H.; Heather L.; Robert A.; John B. (2014). Three-year weight outcomes from a bariatric surgery registry in a large integrated healthcare system. Surgery for Obesity and Related Diseases, 10:396–404.

21. Lee W.J.; Chong K.; Ser K.H.et al. (2011). Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Arch Surg, 146(2):143–8.

22. Lee W.J.; Hur K.Y.; Lakadawala M.et al. (2012). Gastrointestinal metabolic surgery for the treatment of diabetic patients: a multi-institutional international study. J Gastrointest Surg, 16(1):45–51.

23. LeeW.J.; Chong K.; Lin Y.H. et al. (2014). Laparoscopic sleeve gastrectomy versus single anastomosis (mini-) gastric bypass for the treatment of type 2 diabetes mellitus: 5-year results of a randomized trial and study of incretin effect. Obes Surg, 24(9):1552–62.

24. Guenzi M.; Arman G.; Rau C.et al. (2015). Remission of type 2 diabetes after omega loop gastric bypass for morbid obesity. Surg Endosc, Jan 1.

25. Abhishek S.; Padmnabh S.; Rajesh K.; Pragya J. (2014). Effect of sleeve gastrectomy and gastric bypass on diabetic control in Indore, India. Saudi J of obesity, 2(2):59-26.

26. Sanjay S.; Dhiraj A.; Rajkamal K.; Devansh A.; Ankur A.; Ankur K. (2016). Effect of laparoscopic sleeve gastrectomy on lipid profile of obese patients in complete nine month follow up. International Surgery Journal, Feb;3(1):42-46.

27. Brethauer S. A.; Aminian A.; Romero-Ta E.; Mackey J. (2013). Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Ann Surg, 258:628-36.

28. Wilhelm S.M.; Young J.; Kale-Pradhan P.B. (2014). The Effect of Bariatric Surgery on Hypertension: A Meta-analysis. Ann Pharmacother, 48:674-82.

29. Ruiz-Tovar J.; Oller I.; Tomas A.; Llavero C.; Arroyo A. (2012). Midterm impact of sleeve gastrectomy, calibrated with a 50-Fr bougie, on weight loss, glucose homeostasis, lipid profiles, and comorbidities in morbidly obese patients. Am Surg, 78:969-74.

30. Nguyen N.T.; Varela E.; Sabio A. (2006). Resolution of hyperlipidemia after laparoscopic Roux-en-Y gastric bypass. J Am Coll Surg,203(1):24–9.

31. Karamollah T.; Saeed A.; Mahdieh G.; Hossein A. (2011). Effects of Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) on Weight Loss and Biomarker Parameters in Morbidly Obese Patients: A 12-Month Follow-Up. Obes surg, 21:1834–1842.

32. Raffaelli M.; Guidone C.; Callari C. (2014). Effect of gastric bypass versus diet on cardiovascular risk factors. Ann. Surg, 259 (4): 694-699.

33. Marco M.; Roberta L.; Paola M.; Alessandro D.; Paolo B.; Pasquale A.; Guido C.; Francesco M.; Matteo N.; Mario M. (2015). Lipid profile changes in patients undergoing bariatric surgery: A comparative study between sleeve gastrectomy and mini-gastric bypass. International Journal of Surgery; 14:28-32.

Received on 15.04.2017 Modified on 31.06.2017

Research J. Pharm. and Tech. 2017; 10(8): 2517-2521.

DOI: 10.5958/0974-360X.2017.00445.0