Chapitre 7. Article : Association entre les changements de l’ostéocalcine décarboxylée et de l’homéostasie du
8.4 Perspectives
D’un point de vue populationnel, la chirurgie bariatrique est efficace pour améliorer le profil métabolique des individus qui présentent une obésité sévère. La chirurgie bariatrique est efficace pour réduire les comorbidités telles que le diabète de types 2, l’hypertension artérielle et les maladies cardiovasculaires qui alourdissent le fardeau économique du système de santé, et pour réduire la mortalité. Le nombre de chirurgies bariatriques pratiquées au Canada et au Québec est grandissant, et plus du tiers des patients opérés souffrent de diabète de type 2. Il est donc important de reconnaitre les impacts de la chirurgie bariatrique sur le métabolisme osseux, surtout chez des individus ayant déjà une fragilité osseuse secondaire à l’obésité et au diabète de type 2. Plusieurs études ont montré que la DMO était diminuée après tous les types de chirurgie bariatrique (excepté la bande gastrique ajustable), alors que le risque de fracture était augmenté principalement au niveau vertébral, au niveau de la hanche et au niveau du membre supérieur après les chirurgies de type mixtes. Ces fractures de type ostéoporotique entraînent une morbidité et une mortalité importantes, ainsi qu’un fardeau économique sur le système de santé. Cependant, les mécanismes responsables de ces altérations ne sont pas totalement compris, et certaines évidences portent à croire que les changements osseux se manifestent très tôt après la chirurgie, bien que les conséquences visibles, soit les fractures, surviennent généralement dans les années suivantes. Il est donc nécessaire d’investiguer et de comprendre les mécanismes impliqués, pour ensuite cibler des interventions précoces pour limiter la perte osseuse et la détérioration de la microarchitecture osseuse des patients subissant une chirurgie bariatrique. Cela permettra de maximiser le ratio bénéfice/risque de la chirurgie.
Les études futures devront également s’attarder aux changements osseux et au risque de fracture associés à la chirurgie qui est maintenant la plus pratiquée au Canada et dans le monde, la gastrectomie en manchon. Par exemple, il serait nécessaire de réaliser des études longitudinales ayant une taille d’échantillon suffisante pour avoir une bonne puissance statistique, où la gastrectomie en manchon et les chirurgies de type mixtes seraient comparées, et où la DMO et la qualité osseuse (marqueurs du remodelage osseux et microarchitecture) seraient tous deux mesurés à l’aide d’outils valides et précis pour cette population. De plus, des études rigoureuses devront être menées afin de tester des interventions, par exemple, l’administration d’anti-résorptifs tôt après la chirurgie, pour freiner la perte osseuse et la détérioration de la microarchitecture.
De plus, puisque l’amélioration de la sensibilité à l’insuline apparaît très tôt après la chirurgie bariatrique, donc bien avant une perte de poids significative, ces résultats suggèrent que d’autres mécanismes sont responsables. Il serait ainsi intéressant d’approfondir les associations que nous avons observées entre les changements des marqueurs du remodelage osseux et l’amélioration du métabolisme du glucose. De plus, il serait nécessaire de réaliser des études avec de plus grandes tailles d’échantillon, avec des individus ayant ou non un diabète de type 2, et suite à d’autres types de chirurgie, afin d’avoir une puissance statistique nécessaire pour comparer ces deux populations et valider les associations trouvées entre l’ostéocalcine décarboxylée et les indices d’homéostasie du glucose. De plus, puisque des changements osseux et métaboliques sont également observés suite à une perte de poids non-chirurgicale, il serait intéressant d’analyser si les mêmes associations sont présentes dans un groupe d’individus obèses subissant une perte de poids par un changement des habitudes de vie. Finalement, il serait possible de réaliser une étude chez l’animal pour tester le lien de cause à effet en administrant un anti-résorptif directement après la chirurgie bariatrique. Il serait ainsi possible d’observer si le fait de bloquer la résorption osseuse diminue la décarboxylation de l’ostéocalcine et, par le fait même, réduit l’amélioration de la sensibilité à l’insuline après la chirurgie.
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