Is the Gut the “Sweet Spot” for the Treatment of Diabetes?

  1. Stephanie A. Amiel
  1. Diabetes and Nutrition Science Division, King’s College London, London, U.K.
  1. Corresponding author: Francesco Rubino, francesco.rubino{at}

Oskar Minkowski possessed a rare combination of talents: He was an internist with the intuition of a scientist and the dexterity of a surgeon. One day in 1889, he and his colleague Joseph von Mering at the University of Strasbourg performed a total pancreatectomy in a dog to investigate if pancreatic enzymes were necessary to break down fatty acids in the gut. The dog survived the operation but unexpectedly developed polyuria, thirst, hunger, and glycosuria. Minkowski joined the dots to realize the link between the pancreas and diabetes (1).

This story is just one example of how surgical manipulations of anatomy can play a major role in advancing knowledge about physiology and disease. Many lessons about the functioning of the central nervous system, the pituitary gland, and the adrenals have been learned through the help of a scalpel (2), and Minkowski’s observation provided the fundamental clue that lead to the discovery of insulin by Banting and Best in 1921.

More than a century later, surgery may again provide a unique opportunity to improve our understanding of glucose homeostasis, diabetes, and β-cell growth. Readers of Diabetes will know that a number of gastrointestinal (GI) operations used to cause weight loss (bariatric surgery) has also been shown to cause remission of type 2 diabetes (T2D) (3,4) as well as improvement of hypertension and dyslipidemia (5) and reduction of cardiovascular disease and death associated with diabetes and obesity (6). The mechanisms by which these operations control diabetes have become the subject of intense research in recent years, fueled by the experimental evidence that GI bypass surgeries can induce very rapid antidiabetes effects, independent of weight loss (7).

The pathophysiology of T2D is complex but the disease is characterized by a combination of insulin resistance and defective insulin secretion that …

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