Effect of Roux-en-Y gastric bypass on liver mitochondrial dynamics in a rat model of obesity

Bariatric surgery provides significant and durable improvements in glycemic control and hepatic steatosis, but the underlying mechanisms that drive improvements in these metabolic parameters remain to be fully elucidated. Recently, alterations in mitochondrial morphology have shown a direct link to nutrient adaptations in obesity. Here, we evaluate the effects of Roux-en-Y gastric bypass (RYGB) surgery on markers of liver mitochondrial dynamics in a diet-induced obesity Sprague-Dawley (SD) rat model. Livers were harvested from adult male SD rats 90-days after either Sham or RYGB surgery and continuous high-fat feeding. We assessed expression of mitochondrial proteins involved in fusion, fission, mitochondrial autophagy (mitophagy) and biogenesis, as well as differences in citrate synthase activity and markers of oxidative stress. Gene expression for mitochondrial fusion genes, mitofusin 1 (Mfn1; P < 0.05), mitofusin 2 (Mfn2; P < 0.01), and optic atrophy 1 (OPA1; P < 0.05) increased following RYGB surgery. Biogenesis regulators, peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α; P < 0.01) and nuclear respiratory factor 1 (Nrf1; P < 0.05), also increased in the RYGB group, as well as mitophagy marker, BCL-2 interacting protein 3 (Bnip3; P < 0.01). Protein expression for Mfn1 (P < 0.001), PGC1α (P < 0.05), BNIP3 (P < 0.0001), and mitochondrial complexes I-V (P < 0.01) was also increased by RYGB, and Mfn1 expression negatively correlated with body weight, insulin resistance, and fasting plasma insulin. In the RYGB group, citrate synthase activity was increased (P < 0.02) and reactive oxygen species (ROS) was decreased compared to the Sham control group (P < 0.05), although total antioxidant capacity was unchanged between groups. These data are the first to show an association between RYGB surgery and improved markers of liver mitochondrial dynamics. These observed improvements may be related to weight loss and reduced energetic demand on the liver, which could facilitate normalization of glucose homeostasis and protect against hepatic steatosis.

Which postoperative complications matter most after bariatric surgery? Prioritizing quality improvement efforts to improve national outcomes

BACKGROUND

National quality programs have been implemented to decrease the burden of adverse events on key outcomes in bariatric surgery. However, it is not well understood which complications have the most impact on patient health.

OBJECTIVE

To quantify the impact of specific bariatric surgery complications on key clinical outcomes.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

Data from patients who underwent primary bariatric procedures were retrieved from the MBSAQIP 2015 participant use file. The impact of 8 specific complications (bleeding, venous thromboembolism [VTE], leak, wound infection, pneumonia, urinary tract infection, myocardial infarction, and stroke) on 5 main 30-day outcomes (end-organ dysfunction, reoperation, intensive care unit admission, readmission, and mortality) was estimated using risk-adjusted population attributable fractions. The population attributable fraction is a calculated measure taking into account the prevalence and severity of each complication. The population attributable fractions represents the percentage reduction in a given outcome that would occur if that complication were eliminated.

RESULTS

In total, 135,413 patients undergoing sleeve gastrectomy (67%), Roux-en-Y gastric bypass (29%), adjustable gastric banding (3%), and duodenal switch (1%) were included. The most common complications were bleeding (.7%), wound infection (.5%), urinary tract infection (.3%), VTE (.3%), and leak (.2%). Bleeding and leak were the largest contributors to 3 of 5 examined outcomes. VTE had the greatest effect on readmission and mortality.

CONCLUSION

This study quantifies the impact of specific complications on key surgical outcomes after bariatric surgery. Bleeding and leak were the complications with the largest overall effect on end-organ dysfunction, reoperation, and intensive care unit admission after bariatric surgery. Furthermore, our findings suggest that an initiative targeting reduction of post-bariatric surgery VTE has the greatest potential to reduce mortality and readmission rates.

Total Weight Loss as the Outcome Measure of Choice After Roux-en-Y Gastric Bypass

BACKGROUND

Currently, there is no agreement on the best method to describe weight loss (WL) after bariatric surgery. The aim of this study is to evaluate short-term outcomes using percent of total body weight loss (%TWL).

METHODS

A single-institution retrospective study of 2420 patients undergoing Roux-en-Y gastric bypass (RYGB) was performed. Suboptimal WL was defined as %TWL < 20 % at 12 months.

RESULTS

Mean preoperative BMI was 46.8 ± 7.8 kg/m(2). One year after surgery, patients lost an average 14.1 kg/m(2) units of body mass index (BMI), 30.0 ± 8.5 %TWL, and 68.5 ± 22.9 %EWL. At 6 and 12 months after RYGB, mean BMI and percent excess WL (%EWL) significantly improved for all baseline BMI groups (p < 0.01, BMI; p = 0.01, %EWL), whereas mean %TWL was not significantly different among baseline BMI groups (p = 0.9). The regression analysis between each metric outcome and preoperative BMI demonstrated that preoperative BMI did not significantly correlate with %TWL at 1 year (r = 0.04, p = 0.3). On the contrary, preoperative BMI was strongly but negatively associated with the %EWL (r = -0.52, p < 0.01) and positively associated with the BMI units lost at 1 year (r = 0.56, p < 0.01). In total, 11.3 % of subjects achieved <20 %TWL at 12 months and were considered as suboptimal WL patients.

CONCLUSION

The results of our study confirm that %TWL should be the metric of choice when reporting WL because it is less influenced by preoperative BMI. Eleven percent of patients failed to achieve successful WL during the in the first year after RYGB based on our definition.

Pancreatoduodenectomy after Roux-en-Y gastric bypass: technical considerations and outcomes

BACKGROUND

Patients with altered anatomy due to Roux-en-Y gastric bypass (RYGB) present unique diagnostic and therapeutic challenges when they present with periampullary pathology. We describe a series of patients who underwent pancreatoduodenectomy (PD) after gastric surgery with Roux-en-Y reconstruction and review the literature to highlight technical considerations and outcomes.

METHODS

Patients from two institutions were identified and data regarding preoperative workup, operative conduct, and pathologic and clinical outcomes were collected.

RESULTS

Eleven patients were included in the institutional series. At the time of periampullary pathology, the median age was 64 years and time since RYGB was 10 years. Median operative time was 361 minutes, estimated blood loss was 500 mLs, and length of stay was 6 days. Remnant gastrectomy was performed in nine patients and reconstruction was performed using the biliopancreatic limb (BP) without revision of the jejuno-jejunostomy in ten patients. Pathology revealed pancreatic cancer (8), chronic pancreatitis (2), and duodenal cancer (1). Three patients experienced major complications and there were no 90-day mortalities.

CONCLUSION

Pancreatic surgeons will see an increasing number of patients with Roux-en-Y anatomy who will require evaluation and resection for periampullary diseases. For PD after RYGB, we recommend remnant gastrectomy with reconstruction using the BP limb.

American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016

BACKGROUND

Bariatric surgery, despite being the most successful long-lasting treatment for morbid obesity, remains underused as only approximately 1% of all patients who qualify for surgery actually undergo surgery. To determine if patients in need are receiving appropriate therapy, the American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of use for obesity treatment interventions.

OBJECTIVES

The objective of this study was to determine metabolic and bariatric procedure trends since 2011 and to provide the best estimate of the number of procedures performed in the United States in 2016.

SETTING

United States.

METHODS

We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and outpatient centers were used to estimate outpatient center activity. Data from 2016 were compared with the previous 5 years of data.

RESULTS

Compared with 2015, the total number of metabolic and bariatric procedures performed in 2016 increased from approximately 196,000 to 216,000. The sleeve gastrectomy trend is increasing, and it continues to be the most common procedure. The gastric bypass and gastric band trends continued to decrease as seen in previous years. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Finally, intragastric balloons placement emerged as a significant contributor to the cumulative total number of procedures performed.

CONCLUSIONS

There is increasing use of metabolic and bariatric procedures performed in the United States from 2011 to 2016, with a nearly 10% increase noted from 2015 to 2016.

Effect of Roux-en-Y Gastric Bypass on the NLRP3 Inflammasome in Pancreatic Islets from Zucker Diabetic Fatty Rats

PURPOSE

Diabetes and obesity are associated with inflammasome-mediated low-grade, chronic inflammation that may induce pancreatic beta-cell dysfunction and apoptosis. We examined the effects of Roux-en-Y gastric bypass (RYGB) surgery on NOD-like receptor family, pyrin domain containing-3 (NLRP3) inflammasome-related genes from pancreatic islets of Zucker diabetic fatty rats.

MATERIALS AND METHODS

Islets were collected from Zucker diabetic fatty sham control and RYGB, 30 days after surgery. We assessed expression of genes that regulate glucose metabolism and the NLRP3 inflammasome (NLRP3, caspase-1, IL-1β, IL-18, apoptosis-associated speck-like protein), IL-6, and monocyte chemoattractant protein-1.

RESULTS

Gene expression for NLRP3 (p < 0.02), IL-1β (p < 0.04), and IL-6 (p < 0.01) was reduced by RYGB and positively correlated with change in body weight. IL-1β positively correlated with glucose AUC response.

CONCLUSION

Suppression of the NLRP3 inflammasome in pancreatic islets may contribute to improved glycemic control after RYGB.

Robotic platform for gastric bypass is associated with more resource utilization: an analysis of MBSAQIP dataset

BACKGROUND

The current literature comparing robot-assisted Roux-en-Y gastric bypass (RA-RYGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) is limited to single center retrospective series.

OBJECTIVES

This study aims to compare perioperative outcomes of patients who underwent RA-RYGB with those who underwent LRYGB.

SETTING

National database.

METHODS

Data on patients who underwent RA-RYGB and LRYGB were extracted from the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use file. A 1:8 propensity score matching (RA-RYGB:LRYGB) was performed, and the 30-day outcomes of the propensity-matched cohorts were compared.

RESULTS

In total, 36,158 patients met inclusion criteria, including 2660 RA-RYGB (7.4%) cases, which were propensity matched (1:8) with 21,280 LRYGB cases having similar preoperative characteristics. RA-RYGB was associated with longer median operative time (136 versus 107 min; P<.001) and a higher 30-day readmission rate (7.3% versus 6.2%; P = .03). There were no statistical differences between the RA-RYGB and LRYGB cohorts with respect to all-cause morbidity (10.6% versus 10.7%; P = .8), serious morbidity (1.2% versus 1.7%; P = .07), mortality (0.1% versus .2%; P = .2), unplanned intensive care unit admission (1.1% versus 1.3%; P = .3), reoperation (2.4% versus 2.4%; P = .97), or reintervention (3.0% versus 2.5%; P = .2) within 30 days after surgery.

CONCLUSION

Based on available national data, RA-RYGB appears safe compared with a conventional laparoscopic approach for gastric bypass. However, RA-RYGB was associated with longer operative time and higher readmission rate, indicating greater resource use. Further studies are needed to better delineate the role of robotic platforms in bariatric surgery.

Effect of Gastrogastric Fistula Closure in Type 2 Diabetes

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) has been shown to significantly improve glucose control in patients with type 2 diabetes (T2DM). The formation of a gastrogastric fistula (GGF) allows nutrients to pass through the native route, rather than bypassing the duodenum in typical RYGB configuration. We sought to evaluate the effect of revisional bariatric surgery for known GGF on control of diabetes.

METHODS

A retrospective chart review of a single academic institution was performed to identify patients who had T2DM at the time of corrective surgery for a GGF. Baseline characteristics, and postoperative outcomes including changes in body mass index (BMI), glycated hemoglobin, fasting blood glucose (FBG), and diabetes medications were assessed.

RESULTS

Ten patients were identified with GGF who had T2DM at the time of corrective surgery. Patients had a male-to-female ratio of 2:3, a mean age of 59.2 ± 10 years, a mean baseline BMI of 38.1 ± 17.6 kg/m², and a median duration of 9 years (interquartile range 6-14) from initial RYGB to revision. At a mean follow-up of 14.9 ± 8.5 months, a mean reduction in BMI of 4.9 ± 6 kg/m² was associated with a significant mean reduction in FBG (167.1 ± 88.2 vs. 106.1 ± 20.4 mg/dL, p = 0.04) and number of diabetes medications (1.4 ± 0.8 vs. 0.7 ± 0.7, p = 0.04).

CONCLUSION

In patients with diabetes and GGF, a corrective surgery for closure of fistula and restoration of bypass anatomy results in improvement of glucose control and status of diabetes medications. This finding can highlight the potential metabolic significance of duodenal exclusion.

Early Postoperative Outcomes of Primary Bariatric Surgery in Patients on Chronic Steroid or Immunosuppressive Therapy

BACKGROUND

Previous research suggests that patients on chronic steroids may be at an increased risk of postoperative morbidity after major surgery. We aimed to evaluate the prognostic impact of chronic use of steroid or immunosuppression on 30-day morbidity and mortality rates after primary bariatric surgery.

METHODS

From American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent primary bariatric surgery between 2005 and 2013. Logistic regression was used to determine the prognostic impact of chronic use of steroid or immunosuppression on the 30-day postoperative outcomes.

RESULTS

One thousand two hundred seventy seven steroid/immunosuppressant-dependent (SD) and 112,892 non-dependent (ND) patients were analyzed. SD patients had a higher baseline risk profile compared to ND patients. Thirty-day mortality rates for SD and ND patients were 0.55 and 0.11 %, respectively (P < 0.001) which corresponds to an adjusted odds ration (OR) of 6.85 (95 % confidence interval (CI) 1.95-24.12). SD patients had a higher 30-day major morbidity compared to ND patients (5.01 versus 2.54 %; P < 0.001, respectively). After adjustment, this translated into an OR of 2.21 (95 % CI 1.29-3.79). Among SD patients, there was no significant difference in 30-day major morbidity after gastric bypass compared to sleeve gastrectomy (OR = 0.36; 95 % CI 0.08-1.66).

CONCLUSIONS

Chronic and active use of steroid or immunosuppressant medications is a strong predictor of 30-day postoperative morbidity and mortality following primary bariatric surgery. Among the steroid/immunosuppressant users, complication rates were similar for gastric bypass and sleeve gastrectomy patients. Further studies are needed to help guide the management or discontinuation of such medications in the perioperative period.

Bariatric surgery may reduce the risk of Alzheimer's diseases through GLP-1 mediated neuroprotective effects

Obesity and diabetes are associated with deficits in multiple neurocognitive domains and increased risk for dementia. Over the last two decades, there has been a significant increase in bariatric and metabolic surgery worldwide, driven by rising intertwined pandemics of obesity and diabetes, along with improvement in surgical techniques. Patients undergoing bariatric surgery achieve a significant decrease in their excess weight and a multitude of sequela associated with obesity, diabetes, and metabolic syndrome. Glucagon-like peptide 1 (GLP-1) is an intestinal peptide that has been implicated as one of the weight loss-independent mechanisms in how bariatric surgery affects type 2 diabetes. GLP-1 improves insulin secretion, inhibits apoptosis and induce pancreatic islet neogenesis, promotes satiety, and can regulate heart rate and blood pressure. Moreover, numerous studies have demonstrated potential neuroprotective and neurotrophic effects of GLP-1. Increased GLP-1 activity has been shown to increase cortical activity, promote neuronal growth, and inhibit neuronal degeneration. Specifically, in experimental studies on Alzheimer's disease, GLP-1 decreases amyloid deposition and neurofibrillary tangles. Furthermore, recent studies have also suggested that GLP-1 based therapies, new class of antidiabetic drugs, have favorable effects on neurodegenerative disorders such as Alzheimer's disease. We present a hypothesis that bariatric surgery can help delay or even prevent the onset of Alzheimer's disease in long-term by increasing the levels of GLP-1. This hypothesis has a potential for many studies from basic science projects to large population studies to fully understand the neurological and cognitive consequences of bariatric surgery and associated rise in GLP-1.

Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube Placement: A Single Institution Experience and Outcomes to 30 Days and Beyond

INTRODUCTION

Patients with prior foregut surgery requiring long-term enteral access typically undergo operative jejunostomy tube placement; however, direct percutaneous endoscopic jejunostomy (DPEJ) is a viable alternative.

METHODS

All de novo DPEJ procedures performed by surgical and advanced endoscopists from May 2003 to June 2015 were retrospectively reviewed following approval by the Institutional Review Board. There were 59 cases identified.

RESULTS

Our cohort had a mean age of 50.3 ± 16.9 years and 35 (59.3%) were female. All but two patients previously had foregut surgery including 19 patients (34.5%) with prior bariatric surgery. The composite of malnutrition and dehydration was the indication for DPEJ in 29 patients (49.1%) and was the initial enteral access placed in 47 patients (79.7%). Moderate sedation was used in 32 cases (54.2%), and 29 procedures (49.2%) were performed in the operating room. Within 30 days, there were six complications in five patients, giving a peri-procedural complication rate of 12.5%. Beyond 30 days, the most common complications were peri-tube leakage and dislodgement (each 16.9%). The median time to complication was 197 days.

CONCLUSIONS

In patients with surgically altered foregut anatomy, DPEJ offers a less invasive alternative to operative jejunostomy tube placement. DPEJ can be placed in the endoscopy suite or operating room with an acceptable risk of perioperative complications.

Bariatric Surgery versus Intensive Medical Therapy for Diabetes - 5-Year Outcomes

BACKGROUND

Long-term results from randomized, controlled trials that compare medical therapy with surgical therapy in patients with type 2 diabetes are limited.

METHODS

We assessed outcomes 5 years after 150 patients who had type 2 diabetes and a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of 27 to 43 were randomly assigned to receive intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy. The primary outcome was a glycated hemoglobin level of 6.0% or less with or without the use of diabetes medications.

RESULTS

Of the 150 patients who underwent randomization, 1 patient died during the 5-year follow-up period; 134 of the remaining 149 patients (90%) completed 5 years of follow-up. At baseline, the mean (±SD) age of the 134 patients was 49±8 years, 66% were women, the mean glycated hemoglobin level was 9.2±1.5%, and the mean BMI was 37±3.5. At 5 years, the criterion for the primary end point was met by 2 of 38 patients (5%) who received medical therapy alone, as compared with 14 of 49 patients (29%) who underwent gastric bypass (unadjusted P=0.01, adjusted P=0.03, P=0.08 in the intention-to-treat analysis) and 11 of 47 patients (23%) who underwent sleeve gastrectomy (unadjusted P=0.03, adjusted P=0.07, P=0.17 in the intention-to-treat analysis). Patients who underwent surgical procedures had a greater mean percentage reduction from baseline in glycated hemoglobin level than did patients who received medical therapy alone (2.1% vs. 0.3%, P=0.003). At 5 years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (-23%, -19%, and -5% in the gastric-bypass, sleeve-gastrectomy, and medical-therapy groups, respectively), triglyceride level (-40%, -29%, and -8%), high-density lipoprotein cholesterol level (32%, 30%, and 7%), use of insulin (-35%, -34%, and -13%), and quality-of-life measures (general health score increases of 17, 16, and 0.3; scores on the RAND 36-Item Health Survey ranged from 0 to 100, with higher scores indicating better health) (P<0.05 for all comparisons). No major late surgical complications were reported except for one reoperation.

CONCLUSIONS

Five-year outcome data showed that, among patients with type 2 diabetes and a BMI of 27 to 43, bariatric surgery plus intensive medical therapy was more effective than intensive medical therapy alone in decreasing, or in some cases resolving, hyperglycemia. (Funded by Ethicon Endo-Surgery and others; STAMPEDE ClinicalTrials.gov number, NCT00432809 .).

Trends in utilization of bariatric surgery, 2010-2014: sleeve gastrectomy dominates

BACKGROUND

Bariatric surgery is the most effective treatment for morbid obesity. Furthermore, the proportion of various types of bariatric procedures has significantly changed over the last two decades. Sleeve gastrectomy (SG) has been increasingly chosen as a primary bariatric procedure in recent years.

OBJECTIVES

This study aimed to analyze the changing pattern of bariatric surgery utilization from 2010 to 2014.

SETTINGS

Using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014.

METHOD

We identified patients aged≥18 years with a body mass index (BMI)≥35 kg/m² undergoing primary bariatric surgery. The trend of surgical procedures was analyzed from 2010 to 2014.

RESULTS

A total of 93,328 patients were included (age of 44.6±11.8 years and BMI of 46.2±7.9 kg/m²). Roux-en-Y gastric bypass (RYGB), adjustable gastric band, and SG comprised 58.4%, 28.8%, and 9.3% of the procedures in 2010 which changed to 37.6%, 3.1%, and 58.2% in 2014, respectively. Baseline BMI of SG patients decreased from 47.5 to 45.6 kg/m² (P< .001). The proportion of diabetic patients undergoing RYGB increased (30.4% to 33.2%, P<.001) but decreased among those having SG (26.6% to 22.8%, P = .001). The proportion of patients with hypertension having RYGB remained unchanged while decreased among SG patients (56.2% to 47.6%, P<.001). Female patients among the SG group increased from 73.2% to 77.7% (P< .001).

CONCLUSION

SG has been increasingly performed in the United States superseding adjustable gastric band and RYGB. The trend is in favor of females, lower BMI, and lower ratio of patients with diabetes and hypertension. More data are needed on outcomes of SG to assess its long-term effectiveness and credibility.

Outcomes of Bariatric Surgery in Morbidly Obese Patients with Multiple Sclerosis

Obesity is common in patients with multiple sclerosis (MS); however, safety and efficacy of bariatric surgery in this population remain unclear. A database of 2,918 was retrospectively reviewed, yielding 22 (0.75%) severely obese patients with MS who underwent bariatric surgery. Sixteen surgical patients with complete follow-up data were matched to a nonsurgical control group of MS patients, based on age, BMI, MS subtype, and length of follow-up. MS relapse rates and trends in the timed twenty-five foot walk test (T25FW) were compared. In the surgical group (gastric bypass n = 19, sleeve gastrectomy n = 3), preoperative BMI was 46.5 ± 7.2 Kg/m² and average excess weight was 60.4 kg. Follow-up data was collected at 59.0 ± 29.8 months. There were two major and four minor complications. Five patients required readmission and there were no mortalities. Percent excess weight loss was 75.5 ± 27.0%. In the 16 patients with follow-up data, patients who underwent bariatric surgery were significantly faster on the T25FW compared to the nonsurgical population. In conclusion, bariatric surgery is relatively safe and effective in achieving weight loss in patients with MS. In addition, surgery may help patients maintain ambulation. Findings support the need for further studies on bariatric surgery and disease-specific outcomes in this population.

Bariatric Surgery in Obese Patients With Type 1 Diabetes

OBJECTIVE

There is a paucity of data on the impact of bariatric surgery in type 1 diabetes (T1D). The aim of this review was to quantify the overall effects of bariatric surgery in obese patients with T1D.

METHODS

We searched PubMed, Scopus, ISI Web of Knowledge, and Google Scholar from their inception to December 2015 to identify all relevant studies of bariatric surgery in adult obese patients with T1D.

RESULTS

The review included 17 studies with 107 individuals, including 10 case series and 7 case reports. Overall, the dominant procedure was gastric bypass (n = 70; 65%). All studies reported a significant reduction in excess weight. A significant reduction in weight-adjusted daily insulin requirements was shown in all case series except one. Pooled mean ± SD of pre- and postoperative glycated hemoglobin (HbA1c) for the entire cohort with available data (n = 96) was 8.4 ± 1.3% and 7.9 ± 1.1%, respectively (P = 0.01). In addition to common postoperative complications, profound glycemic changes (diabetic ketoacidosis and hypoglycemia) and gastrointestinal dysmotility symptoms (prolonged ileus and acute gastric remnant dilation) have been reported. No surgical mortality was reported.

CONCLUSIONS

Bariatric surgery leads to significant weight loss in severely obese patients with T1D and results in a significant improvement in insulin requirements and glycemic status. The favorable metabolic effects of bariatric surgery may facilitate medical management of and cardiovascular risk reduction in T1D in the setting of severe obesity. Diabetic ketoacidosis and hypoglycemia are potentially serious complications. Short-term results of bariatric surgery in patients with T1D are encouraging, but larger and longer-term studies are needed.

Gastrointestinal devices for the treatment of type 2 diabetes

BACKGROUND

Obesity and type 2 diabetes (T2D) continue to be growing epidemics worldwide. Although bariatric surgery remains the most effective and durable treatment for both of these chronic diseases, there is a need for therapies with risk and benefit profiles between medication and standard surgical procedures. Currently there are several endoscopic and minimally invasive therapies available worldwide to treat T2D.

OBJECTIVE

To review the current evidence regarding the safety and efficacy of medical devices to treat T2D.

SETTING

Academic practice, international

METHODS

The published literature was searched for articles evaluating the safety and efficacy of endoluminal and surgical devices used for the treatment of obesity and T2D.

RESULTS

The current devices in use include intragastric balloons, a duodenal-jejunal liner, gastric content aspiration, and devices that provide neuromodulation to the stomach or vagal nerves. On early phases of first-in-human studies is the duodenal mucosal resurfacing. The current evidence supporting the safety and efficacy of temporary use (6 months) for the intragastric balloon for lower body mass index (BMI) patients is strong and there is growing evidence regarding the effects of the other devices to treat T2D.

CONCLUSIONS

There is a need for novel therapies to bridge the risk and benefit gap between medical and surgical treatment of T2D. The original indication for many of the current devices was treatment of obesity. Several devices that are currently available are promising but require more study in T2D patient populations.