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Diabete

 

IL DIABETE MELLITO  tipo  II, è la forma più comune e meglio conosciuta di diabete, nella gran maggioranza di casi associata a gradi variabili di obesità.

Nella sua forma conclamata il diabete mellito è un’affezione caratterizzata da un aumento stabile della quantità di glucosio circolante nel sangue (iperglicemia) e una conseguente comparsa di questa sostanza nelle urine (glicosuria).

Il diabete mellito è da considerare una sindrome, cioè un quadro morboso che può essere l’effetto di cause di natura diversa, le quali possono agire con meccanismi differenti e nelle quali interagiscono, sebbene in modo variabile, fattori ereditari e fattori ambientali.

Il diabete mellito è un’affezione relativamente comune che, specie nei paesi ad alto tenore di vita, colpisce fino al 5% della popolazione, costituendo, per le complicazioni cui può dar luogo, un’importante causa di mortalità.

Prima di manifestarsi con sintomi clinici apprezzabili,  il diabete può evolvere per un tempo, in genere, piuttosto lungo in modo silente e può essere indicato solo da indagini di laboratorio o da prove funzionali (diabete latente –  si ha già un significativo aumento della glicemia), di diabete  biochimico, quando la glicemia si mantiene ancora nei limiti della norma ma le prove  strumentali,  svelano una ridotta tolleranza al glucosio.

Con il manifestarsi dei sintomi clinici, la malattia può assumere caratteri diversi sia per gravità, sia per evoluzione e sensibilità alle diverse terapie. Difatti, si distinguono due forme principali: il diabete mellito ad insorgenza giovanile  (tipo 1) e quello ad insorgenza in età matura (tipo 2).

Nel diabete di  tipo 1 la patogenesi è legata alla distruzione delle cellule beta-pancreatiche, su base autoimmune, per il diabete di tipo 2, invece,  la sintesi di insulina è ridotta e  si sviluppa anche una resistenza all’azione della stessa, dovuta probabilmente ad un problema recettoriale; il numero delle cellule beta, però, è intatto.

Nell’ambito di queste forme, tuttavia, si presentano casi eterogenei, dovuti ai diversi meccanismi con cui si può manifestare il deficit dell’attività insulinica. Si ritiene, infatti, che possano agire alterazioni genetiche delle cellule produttrici dell’ormone, sintesi di insulina ad attività biologica deficitaria,  meccanismi autoimmunitari, diete particolarmente sbilanciate, oppure infezioni virali.

 

DIABETE MELLITO E CHIRURGIA BARIATRICA

La pratica clinica della chirurgia bariatrica ha ampiamente evidenziato come nei pazienti diabetici obesi si osservi, con frequenza elevata, un miglioramento, se non la completa scomparsa, del diabete di tipo 2 (dell’adulto), con la sospensione o una notevole riduzione della necessità del relativo trattamento farmacologico.
Da uno studio coordinato da Francesco Rubino del Weill Cornell Medical College e da Geltrude Mingrone dell’Università Cattolica di Roma pubblicato sul New England Journal of Medicine si evince che la chirurgia bariatrica ha effetti molto più incisivi sul trattamento del diabete di tipo II rispetto alla terapia medica tradizionale. Lo studio si basa sull’analisi di 60 pazienti affetti da grave obesità e diabete divisi in tre gruppi. Il primo è stato trattato mediante trattamento farmacologico, il secondo con un bypass gastrico (intervento misto restrittivo-malassorbitivo) e il terzo con una diversione biliopancreatica (intervento con preponderante componente malassorbitiva). A distanza di due anni dal trattamento, il 95% dei pazienti che hanno subito la diversione biliopancreatica è risultato essere completamente guarito dal diabete, contro il 75% dei pazienti sottoposti a bypass gastrico. I pazienti trattati invece farmacologicamente non hanno dimostrato in nessun caso remissione di malattia.
Si può pertanto dedurre che nel paziente obeso (con BMI superiore a 35) la chirurgia dell’obesità può portare alla guarigione completa del diabete.
Inoltre durante la “International Conference on Gastrointestinal Surgery to treat type 2 Diabetes”,tenutasi a Roma nel 2007, sono state estese le indicazioni per la chirurgia bariatrica ai pazienti diabetici con obesità moderata (BMI tra 30 e 35).

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