Sleeve gastrectomy and type 2 diabetes mellitus: a systematic review

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

MAFB mediates the therapeutic effect of sleeve gastrectomy for obese diabetes mellitus by activation of FXR expression

Farnesoid X receptor (FXR) and related pathways are involved in the therapeutic effect of sleeve gastrectomy for overweight or obese patients with diabetes mellitus. This study aimed to investigate the mechanism of FXR expression regulation during the surgical treatment of obese diabetes mellitus by sleeve gastrectomy. Diabetic rats were established by combined streptozotocin and high-fat diet induction. Data collection included body weight, chemical indexes of glucose and lipid metabolism, liver function, and the expression levels of musculoaponeurotic fibrosarcoma oncogene family B (MAFB), FXR, and related genes induced by sleeve gastrectomy. Chang liver cells overexpressing MAFB gene were established to confirm the expression of related genes. The binding and activation of FXR gene by MAFB were tested by Chip and luciferase reporter gene assays. Vertical sleeve gastrectomy induced significant weight loss and decreased blood glucose and lipids in diabetic rat livers, as well as decreased lipid deposition and recovered lipid function. The expression of MAFB, FXR, and FXR-regulated genes in diabetic rat livers were also restored by sleeve gastrectomy. Overexpression of MAFB in Chang liver cells led to FXR gene expression activation and the alteration of multiple FXR-regulated genes. Chip assay showed that MAFB could directly bind with FXR promoter, and the activation of FXR expression was confirmed by luciferase reporter gene analysis. The therapeutic effect of sleeve gastrectomy for overweight or obese patients with diabetes mellitus was mediated by activation of FXR expression through the binding of MAFB transcription factor.

Weight Loss and Glycemic Control after Sleeve Gastrectomy: Results from a Middle Eastern Center of Excellence

Obesity and its associated metabolic disorders are strongly linked to both morbidity and mortality. Sleeve gastrectomy (SG) has been established as an effective means of weight loss for obese patients as well as a treatment for type 2 diabetes mellitus (T2DM). This study was designed to examine the short- and midterm outcomes of patients who underwent SG in a Middle Eastern Center of Excellence, a military training teaching hospital. The clinical outcomes of 59 patients with impaired glucose tolerance and T2DM who underwent SG between 2011 and 2014 with at least one and up to four years of follow-up were studied. Data were collected and compared, including the pre- and post-surgery measures of weight, body mass index, glycosylated hemoglobin (HbA1c), and fasting blood glucose. Complete remission was defined as a fasting blood glucose level ≤100 mg/dL, an HbA1c ≤6 mg/dL, without use of antidiabetic medications. All patients showed significant reduction in body mass index following SG. Tight glycemic control was achieved among both diabetic and prediabetic patients. In this study, 88.14 per cent of all patients (diabetic and prediabetic) achieved complete resolution from their impaired glucose tolerance and T2DM and maintained normal blood glucose and HbA1C levels from one to four years post-operatively. SG is beneficial both in terms of short- and midterm weight loss and glucose control in both diabetic and prediabetic obese patients.

Is there a Reason Why Obese Patients Choose Either Conservative Treatment or Surgery?

BACKGROUND

The effects of bariatric surgery on excess weight loss (EWL) and comorbidities are proven. Still, a significant number of patients prefer conservative therapy (ConsP).

OBJECTIVES

The goal of this study was to examine why ConsP and patients awaiting bariatric surgery (SurgP) choose which therapy, and to define the differences in their expectations.

SETTING

Prospective study, 1 university hospital, 1 general hospital, Germany.

METHODS

ConsP and SurgP were asked to complete a questionnaire. Statistical analysis including all patients and a BMI-matched cohort was performed using the chi-square and Wilcoxon rank-sum test.

RESULTS

Overall, 151 patients participated in this study (50 ConsP, 101 SurgP, 69.4% females). The mean age was 41.1 years (SD ± 12.2 years). ConsP had a significant lower body mass index (BMI, 44.7 kg/m² vs. 49.3 kg/m², p < 0.01). The educational level was significantly higher in ConsP. SurgP suffered significantly more often from depression (21.6% vs. 36.6%, p = 0.02) and joint pain (45.1% vs. 68.7%, p = 0.02). ConsP completed significantly more diets that were supervised by physicians or considered well-structured (56.3% vs. 31.0%, p = 0.04). SurgP considered their chosen therapy a last resort significantly more often (p < 0.01). A BMI-matched analysis between ConsP and SurgP revealed no significant differences in the prevalence of comorbidities but showed that fear of surgery plays a major role in the decision-making processes of obese patients.

CONCLUSION

A higher BMI and a greater prevalence of comorbidities had driven patients to seek a more radical solution for their obesity, i.e., surgery. The BMI-matched analysis suggests that fear of surgery is a relevant factor in why obese patients do not decide to undergo bariatric surgery lightly.

Laparoscopic Sleeve Gastrectomy: Co-morbidity Profiles and Intermediate-Term Outcomes

BACKGROUND

Bariatric surgery is effective at achieving sustained weight loss and improving the control and resolution of obesity-related co-morbidities. Most studies that have demonstrated co-morbidity resolution in patients undergoing laparoscopic sleeve gastrectomy (LSG) only follow patients for the short term (less than 1 year) or follow a relatively small cohort (<100 patients) for the intermediate or long term (more than 5 years). We report our experience following a large cohort of morbidly obese patients who underwent LSG with intermediate-term follow-up.

METHODS

We retrospectively reviewed 435 consecutive patients who underwent LSG from January 2004 to November 2013. Co-morbidities investigated included diabetes mellitus (DM), hypertension (HTN), and hyperlipidemia (HL). A co-morbidity was determined to be resolved if the patient was no longer taking any medication to treat that specific co-morbidity.

RESULTS

Mean follow-up was 26 ± 25 months (range = 1-112). Mean postoperative total weight loss (%TWL) at 6, 12, 24, 36, 48, 60, and 72 months were 23.6, 29.9, 29.5, 25.2, 26.7, 25.4, and 24.3 %, respectively. The incidence of all three co-morbidities was found to be significantly lower at the last patient follow-up. The resolution rates for DM, HTN, and HL were 59, 31, and 50 %, respectively. In patients who continued to have co-morbidities, the mean numbers of medications for DM (1.2 ± 0.7 vs. 0.5 ± 0.7, p < 0.0001), HTN (1.8 ± 1.1 vs. 1.3 ± 1.2, p < 0.0001), and HL (0.9 ± 0.7 vs. 0.6 ± 0.6, p < 0.0001) postoperatively were all significantly less.

CONCLUSIONS

LSG is effective at achieving significant and sustained weight loss, improvement in co-morbidity profiles, and a reduction in poly-pharmacy for these conditions over intermediate-term follow-up.

Resolution of type 2 diabetes after sleeve gastrectomy: a 2-step hypothesis

BACKGROUND

Weight loss (WL) and altered gut hormonal levels are involved in glucose homeostasis after laparoscopic sleeve gastrectomy (LSG).

OBJECTIVES

The aim of this study was to evaluate the time-related effects of WL, ghrelin, and glucacon-like peptide-1 (GLP-1) plasma concentrations on type 2 diabetes resolution after LSG.

SETTING

University hospital, Italy.

METHODS

Ninety-one patients who underwent LSG were investigated. Insulin secretion (insulinogenic index [IGI]), insulin resistance, plasma glucose level and percentage glycated hemoglobin using the oral glucose tolerance test were assessed before surgery, on postoperative day 3, and then at 6, 12, 24, and 36 months after LSG. At the same time points, WL, ghrelin, and GLP-1 levels were determined.

RESULTS

During follow-up, the resolution rate of type 2 diabetes was 9.4%, 42.3%, 71.8%, 81.2%, and 91.8%, respectively. Ghrelin plasma concentrations decreased significantly after LSG (271.5 ± 24.5 pg/mL versus 122.4 ± 23.4 pg/mL, P = .04). GLP-1 plasma concentrations increased significantly after LSG (1.7 ± 2.6 pg/mL versus 2.5 ± 3.4 pg/mL, P = .04). The percentage of excess weight loss and IGI presented a positive linear correlation (r) at all follow-up time points with a strong positive correlation at 12 and 24 months. A strong negative correlation between ghrelin and IGI was recorded during the first 3 days after LSG (r = -.9). GLP-1 and IGI presented a strong positive correlation at day 3 and 6 months (i.e., .8 and .8, respectively).

CONCLUSION

LSG may affect glucose homeostasis by 2 different time-related modes: a first step in which the hormonal changes play a predominant role in glucose homeostasis and a second step in which the percentage excess weight loss determines the metabolic results.

Investigating Nutritional Deficiencies in a Group of Patients 3 Years Post Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure has shown to be effective in achieving significant weight loss and resolving obesity-related co-morbidities. However, its nutrition consequences have not been extensively explored. This study aims to investigate weight loss and evolution of nutritional deficiencies in a group of patients 3 years post LSG.

METHODS

Retrospective data of a group of patients, 3 years following LSG as a stand-alone procedure was collected. Data included anthropometry, nutritional markers (hemoglobin, iron studies, folate, calcium, iPTH, vitamins D, and B₁₂), and compliancy with supplementations.

RESULTS

Ninety-one patients (male/female; 28:63), aged 51.9 ± 11.4 years with a BMI of 42.8 ± 6.1 kg/m² were identified to be 3 years post LSG. Percentage of weight loss at 1 and 3 years post-operatively was 29.8 ± 7.0 and 25.9 ± 8.8 %, respectively. Pre-operatively, the abnormalities included low hemoglobin (4 %), ferritin (6 %), vitamin B₁₂ (1 %), vitamin D (46 %), and elevated iPTH (25 %). At 3 years post-operatively, the abnormal laboratory values included low hemoglobin (14 % females, P = 0.021), ferritin (24 %, P = 0.011), vitamin D (20 %, P = 0.018), and elevated iPTH (17 %, P = 0.010). Compliancy with multivitamin supplementation was noted in 66 % of patients.

CONCLUSION

In these patients, LSG resulted in pronounced weight loss at 1 year post-operatively, and most of this was maintained at 3 years. Nutritional deficiencies are prevalent among patients prior to bariatric surgery. These deficiencies may persist or exacerbate post-operatively. Routine nutrition monitoring and supplementations are essential to prevent and treat these deficiencies.

QUALITY OF LIFE AFTER VERTICAL GASTRECTOMY EVALUATED BY THE BAROS QUESTIONNAIRE

BACKGROUND

The satisfactory outcome in the surgical treatment of obesity must include, in addition to weight loss, a significant change in the pre-existing comorbidities and in the quality of life of the patients.

AIM

To evaluate the quality of life in the late postoperative period in patients that underwent videolaparoscopic sleeve gastrectomy.

METHODS

Was applied the questionnaire "Bariatric Analysis and Reporting Outcome System" (BAROS) in patients that underwent videolaparoscopic sleeve gastrectomy.

RESULTS

A total of 47 patients between 21-60 years old were evaluated. The total mean of the BMI before surgery was 43.06±5.87 kg/m². The average percentage of the reduction of excess weight after surgery was 85.46±23.6%. The score obtained by patients in the questionnaire about the improvement in the quality of life showed excellent (36.17%), very good (40.43%), good (21.28%) and reasonable (2.13%) results. There was clinical improvement after surgery in all comorbidities investigated.

CONCLUSION

BAROS showed excellent results in 36.17%, very good in 40.43%, good in 21.28% and reasonable in 2.13%. The weight loss was critical to improve the quality of life and offered the resolution or clinical improvement in all of the investigated comorbidities.

Outcomes of One Anastomosis Gastric Bypass in 472 Diabetic Patients

BACKGROUND

The positive impact of Roux-en-Y gastric bypass (RYGB) on metabolic syndrome and glycemic control has been proven in obese patients. One anastomosis gastric bypass (OAGB) is a simple, effective and easy to learn procedure. OAGB provides encouraging results for the treatment of diabetes obese patients, but does it have the ability to be an alternative procedure to RYGB in the treatment of these patients? The aim of this study is to evaluate the outcomes of OAGB on diabetic obese patients at the bariatric centre of our university hospital. By extension, we evaluated the possibility of BMI and the preoperative antidiabetic medication usage to be predictive factors for postoperative diabetes resolution.

METHODS

This is a retrospective single-centre study of 472 diabetic patients who underwent OAGB from November 2009 to December 2015. All patients were followed-up for at least 1 year, and up to 3 years, where available. Weight, HbA1c, and anti-diabetic medications were recorded at baseline, 3, 6, 12, 24 and 36 months.

RESULTS

A total of 472 patients have been followed-up for 1 year and 361 for 3 years. The mean BMI decreased from 46.8 ± 7.2 to 29.5 ± 2.8 kg/m² and HbA1c from 9.6 ± 1.3 to 5.7 ± 1.5% at the 12-month follow-up. At the 3-year follow-up, the mean BMI was 32.1 ± 3.3 and HbA1c mean was 5.8 ± 0.9%. Diabetes remission was achieved by 84.1% of patients.

CONCLUSIONS

OAGB can be an excellent alternative to RYGB for the treatment of diabetes and obesity. Pre-operative medications may be used to predict postoperative diabetes remission, but not BMI.

Long-term effects of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass for the treatment of morbid obesity: a monocentric prospective study with minimum follow-up of 5 years

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most widely used bariatric procedures nowadays. The aim of this study was to compare long-term results on weight loss and comorbidities improvement for both procedures. A cohort of 304 consecutive patients underwent surgery in 2006-2009: 162 underwent LSG and 142 underwent LRYGB. The mean follow-up time was 75.8 ± 8.4 months (range 60-96). LSG showed greater effectiveness in percentage of excess weight loss (%EWL) at 180 days and at 1 year of follow-up. Instead, at 5th year follow-up LRYGB and LSG showed similar %EWL values (72.34 versus 70.26). LSG group showed a lack of weight loss in patients from 3 to 5 years after surgery, whereas LRYGB group patients maintained an effective weight loss during the entire follow-up period. In LSG group both length of stay and operative time were found to be shorter. LRYGB showed better effectiveness in type 2 diabetes mellitus (T2DM) resolution rate. None of the two techniques has proven to be clearly better than the other on a long-term follow-up analysis, except for the LRYGB better results in T2DM healing. According to our findings, in LSG Group after 3 years the weight remains stable.

PRELIMINARY ANALYSIS OF INTERLEUKIN-6 CHANGES IN PRE- AND POSTOPERATIVE IN DIABETIC PATIENTS WITH BMI<35 SUBMITTED TO PARTIAL DUODENAL SWITCH

Background:

Studies related to obesity have shown association with metabolic syndrome. Data showing that obesity is capable to cause low grade chronic inflammation, without its classic signs and symptoms, call attention to researches to study different cells types and the mechanism of the inflammatory process.

Aim:

To evaluate the variation of glycated hemoglobin (HbA1c) and the pro-inflammatory cytokine interleukin-6 (IL6) in diabetic patients with BMI <35 kg/m² in the pre and postoperative of partial duodenal switch.

Method:

Nine patients were studied before and one year after the operation and the variation of the serum IL6 was measured by Elisa. The changes of HbA1c were also registered.

Results:

The pre-operative IL6 levels reached 65,50436±2,911993 pg/ml and one year after de operation 39,47739±3,410057 and the HbA1c average of 10,67 and 5.8 in the same period.

Conclusion:

The partial duodenal switch was efficient to control one year after the procedure the chronic inflammatory process caused by the diabetes mellitus type 2 with BMI <35 by dropping the IL6 levels and bringing the HbA1c to normal.

QUALITY OF LIFE AFTER VERTICAL GASTRECTOMY EVALUATED BY THE BAROS QUESTIONNAIRE

Background

The satisfactory outcome in the surgical treatment of obesity must include, in addition to weight loss, a significant change in the pre-existing comorbidities and in the quality of life.

Aim

To evaluate the quality of life in the late postoperative period in patients that underwent videolaparoscopic sleeve gastrectomy.

Methods

It was applied the questionnaire "Bariatric Analysis and Reporting Outcome System" (BAROS) in patients that underwent videolaparoscopic sleeve gastrectomy.

Results

A total of 47 patients between 21-60 years old were evaluated. The total mean of BMI before surgery was 43.06±5.87 kg/m². The average percentage of the reduction of excess weight after surgery was 85.46±23.6%. The score obtained by patients in the questionnaire about the improvement in the quality of life showed excellent (36.17%), very good (40.43%), good (21.28%) and reasonable (2.13%) results. There was clinical improvement after surgery in all comorbidities investigated.

Conclusion

The weight loss was critical to improve the quality of life and offered the resolution or clinical improvement in all of the investigated comorbidities in patients submitted to sleeve gastrectomy.

Excess Body Mass Index Loss at 3 Months: A Predictive Factor of Long-Term Result after Sleeve Gastrectomy

Introduction. Laparoscopic Sleeve Gastrectomy (SG) is considered as successful if the percentage of Excess Body Mass Index Loss (% EBMIL) remains constant over 50% with long-term follow-up. The aim of this study was to evaluate whether early % EBMIL was predictive of success after SG. Methods. This retrospective study included patients who had SG with two years of follow-up. Patients had follow-up appointments at 3 (M3), 6, 12, and 24 months (M24). Data as weight and Body Mass Index (BMI) were collected systematically. We estimated the % EBMIL necessary to establish a correlation between M3 and M24 compared to % EBMIL speeds and calculated a limit value of % EBMIL predictive of success. Results. Data at operative time, M3, and M24 were available for 128 patients. Pearson test showed a correlation between % EBMIL at M3 and that at M24 (r = 0.74; p < 0.0001). % EBMIL speed between surgery and M3 (p = 0.0011) was significant but not between M3 and M24. A linear regression analysis proved that % EBMIL over 20.1% at M3 (p < 0.0001) predicted a final % EBMIL over 50%. Conclusions. % EBMIL at M3 after SG is correlated with % EBMIL in the long term. % EBMIL speed was significant in the first 3 months. % EBMIL over 20.1% at M3 leads to the success of SG.

Bariatric Surgery: Pathophysiology and Outcomes

Diabetes mellitus and obesity are closely interrelated and pose a major burden on health care in terms of morbidity and mortality. Weight loss has favorable metabolic benefits for glycemic control and improvement of metabolic syndrome. Bariatric surgery (BS) is the most effective treatment for weight loss with durable results as compared to lifestyle modification. BS procedures have been associated with significant reduction in abdominal obesity, metabolic syndrome components, and glycemic control requiring fewer medications. Long-term risks of surgery include nutritional deficiencies, osteoporosis, bone fractures, and hyperinsulinemic hypoglycemia, which need to be carefully balanced with metabolic benefits for individual patients.

Impact of preoperative body mass index on the final outcome after laparoscopic sleeve gastrectomy for morbid obesity

OBJECTIVE

Laparoscopic sleeve gastrectomy (LSG) is a popular bariatric surgery due to its excellent results and limited morbidity. Our study aims to assess the efficacy of LSG in terms of loss of weight and co-morbidity improvement and to evaluate the impact of preoperative body mass index (BMI) on the final outcome.

MATERIAL AND METHODS

The data of 173 patients who underwent LSG were analyzed. Laparoscopic sleeve gastrectomy was indicated only for patients with BMI >40. Mean postoperative BMI, co-morbidity improvement, operative data and complications, length of hospital stay and excess weight loss were evaluated and recorded.

RESULTS

This study included 151 females and 22 males with a mean age of 37.6 years. Patients were divided into two groups according to their BMI (group I <50, group II >50). Mean preoperative BMI was 53.8 kg/m2. Mean operative time was 120 minutes. Mean duration of hospital stay was 3.2 days. Mean postoperative BMI decreased to 47.3 kg/m2 at 1 year. Excess weight loss was 43.1% at 6 months, 71.1% at 1 year, and 87.5% at 5 years. Group I showed a significantly shorter length of hospital stay, more improvement of laboratory parameters and more reduction in BMI as compared to group II. There was one mortality and six cases had gastric staple line leakage.

CONCLUSION

Laparoscopic sleeve gastrectomy is an efficient treatment to achieve significant weight loss that is maintained up to 5 years of follow up, also it improves some of the obesity related co-morbidities. This beneficial impact of LSG appears to be significantly higher in patients with BMI <50.

Effect of Resected Gastric Volume on Ghrelin and GLP-1 Plasma Levels: a Prospective Study

BACKGROUND

The correlation between resected gastric volume (RGV) and neuro-humoral changes (ghrelin and GLP-1) after laparoscopic sleeve gastrectomy (LSG) and their effects on type 2 diabetes mellitus (T2DM) has been evaluated.

MATERIALS

Ninety-eight patients were divided in two groups: RGV <1200 mL (group A: 53 pts) and RGV >1200 mL (group B: 45 pts). Insulin secretion (insulin area under the curve (AUC)), insulinogenic index (IGI) and insulin-resistance (homeostasis model assessment, HOMA_IR) were assessed before and after surgery (at the 3rd day and 6, 12 and 24 months after LSG) using the oral glucose tolerance test (OGTT). At the same time, ghrelin and GLP-1 levels were determined.

RESULTS

A significant difference in T2DM resolution rate was observed after 6, 12 and 24 months in favour of RGV >1200 mL. Group B performed better than group A at the 3rd day and at the 6th, 12th and 24th months with regard to AUC, IGI and HOMA_IR. In both groups, OGTT resulted in decreased ghrelin values and a significant increase in GLP-1 values for group B at the 3rd day and at the 6th and 12th months with no difference at the 24th month.

CONCLUSION

Ghrelin and GLP-1 changes play a role in the regulation of glucose metabolism during the 1st year after LSG. RGV influences ghrelin and GLP-1 plasma levels after LSG, with a significant improvement in the T2DM control.

The Development of Diabetes after Subtotal Gastrectomy with Billroth II Anastomosis for Peptic Ulcer Disease

PURPOSE

A duodenal bypass after a Roux-en-Y gastric bypass operation for obesity can ameliorate the development of diabetes mellitus (DM). We attempted to determine the subsequent risk of developing DM after subtotal gastrectomy with Billroth II anastomosis (SGBIIA) for peptic ulcer disease (PUD).

METHODS

We identified 662 patients undergoing SGBIIA for PUD between 2000 and 2011 from the Longitudinal Health Insurance Database as the study cohort, and we randomly selected 2647 controls from the peptic ulcer population not undergoing SGBIIA and were frequency-matched by age, sex, and index year for the control cohort. All patient cases in both cohorts were followed until the end of 2011 to measure the incidence of DM. We analyzed DM risk by using a Cox proportional hazards regression model.

RESULTS

The patients who underwent SGBIIA demonstrated a lower cumulative incidence of DM compared with the control cohort (log-rank test, P < .001 and 6.73 vs 12.6 per 1000 person-y). The difference in the DM risk between patients with and without SGBIIA increased gradually with the follow-up duration. Age and sex did not affect the subsequent risk of developing DM, according to the multivariable Cox regression model. Nevertheless, the SGBIIA cohort exhibited a lower DM risk after we adjusted for the comorbidities of hypertension, hyperlipidemia, and coronary artery disease (adjusted hazard ratio (aHR): 0.56, 95% confidence interval (CI): 0.40-0.78). The incidence rate ratio (IRR) of DM in the SGBIIA cohort was lower than that in the control cohort for all age groups (age ≤ 49 y, IRR: 0.40, 95% CI: 0.16-0.99; age 50-64 y, IRR: 0.54, 95% CI: 0.31-0.96; age ≧ 65 y, IRR: 0.57, 95% CI: 0.36-0.91). Moreover, the IRR of DM was significantly lower in the SGBIIA cohort with comorbidities (IRR: 0.50, 95% CI: 0.31-0.78) compared with those without a comorbidity (IRR: 0.65, 95% CI: 0.40-1.04).

CONCLUSION

The findings of this population-based cohort study revealed that SGBIIA was associated with a reduced risk of DM development, and the inverse association was greater in the presence of a comorbidity.

Metabolic syndrome and the hepatorenal reflex

Insufficient hepatic O₂ in animal and human studies has been shown to elicit a hepatorenal reflex in response to increased hepatic adenosine, resulting in the stimulation of renal as well as muscle sympathetic nerve activity and activating the renin angiotensin system. Low hepatic ATP, hyperuricemia, and hepatic lipid accumulation reported in metabolic syndrome (MetS) patients may reflect insufficient hepatic O₂ delivery, potentially accounting for the sympathetic overdrive associated with MetS. This theoretical concept is supported by experimental results in animals fed a high fructose diet to induce MetS. Hepatic fructose metabolism rapidly consumes ATP resulting in increased adenosine production and hyperuricemia as well as elevated renin release and sympathetic activity. This review makes the case for the hepatorenal reflex causing sympathetic overdrive and metabolic syndrome in response to exaggerated splanchnic oxygen consumption from excessive eating. This is strongly reinforced by the fact that MetS is cured in a matter of days in a significant percentage of patients by diet, bariatric surgery, or endoluminal sleeve, all of which would decrease splanchnic oxygen demand by limiting nutrient contact with the mucosa and reducing the nutrient load due to loss of appetite or dietary restriction.

Metabolic syndrome and the hepatorenal reflex

Insufficient hepatic O₂ in animal and human studies has been shown to elicit a hepatorenal reflex in response to increased hepatic adenosine, resulting in stimulation of renal as well as muscle sympathetic nerve activity and activating the renin angiotensin system. Low hepatic ATP, hyperuricemia, and hepatic lipid accumulation reported in metabolic syndrome (MetS) patients may reflect insufficient hepatic O₂ delivery, potentially accounting for the sympathetic overdrive associated with MetS. This theoretical concept is supported by experimental results in animals fed a high fructose diet to induce MetS. Hepatic fructose metabolism rapidly consumes ATP resulting in increased adenosine production and hyperuricemia as well as elevated renin release and sympathetic activity. This review makes the case for the hepatorenal reflex causing sympathetic overdrive and metabolic syndrome in response to exaggerated splanchnic oxygen consumption from excessive eating. This is strongly reinforced by the fact that MetS is cured in a matter of days in a significant percentage of patients by diet, bariatric surgery, or endoluminal sleeve, all of which would decrease splanchnic oxygen demand by limiting nutrient contact with the mucosa and reducing the nutrient load due to the loss of appetite or dietary restriction.

Surgical cure for type 2 diabetes by foregut or hindgut operations: a myth or reality? A systematic review

BACKGROUND

Bariatric surgery results in remission of type 2 diabetes mellitus in a significant proportion of patients. Animal research has proposed the foregut and hindgut hypotheses as possible mechanisms of remission of T2DM independent of weight loss. These hypotheses have formed the basis of investigational procedures designed to treat T2DM in non-obese (in addition to obese) patients. The aim of this study was to review the procedures that utilise the foregut and hindgut hypotheses to treat T2DM in humans.

METHODS

A systematic review was conducted to identify the investigational procedures performed in humans that are based on the foregut and hindgut hypotheses and then to assess their outcomes.

RESULTS

Twenty-four studies reported novel procedures to treat T2DM in humans; only ten utilised glycated haemoglobin A1c (HbA1c) in their definition of remission. Reported remission rates were 20-40 % for duodenal-jejunal bypass (DJB), 73-93 % for duodenal-jejunal bypass with sleeve gastrectomy (DJB-SG), 62.5-100 % for duodenal-jejunal bypass sleeve (DJBS) and 47-95.7 % for ileal interposition with sleeve gastrectomy (II-SG). When using a predetermined level of HbA1c to define remission, the remission rates were lower (27, 63, 0 and 65 %) for DJB, DJB-SG, DJBS and II-SG.

CONCLUSIONS

The outcomes of the foregut- and hindgut-based procedures are not better than the outcomes of just one of their components, namely sleeve gastrectomy. The complexity of these procedures in addition to their comparable outcomes to a simpler operation questions their utility.

Long-term Results on Weight Loss and Diabetes Remission after Laparoscopic Sleeve Gastrectomy for A Morbidly Obese Chinese Population

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is an effective stand-alone bariatric procedure with favorable short-term results on weight reduction and comorbidity resolution. This study aims to evaluate the long-term results of LSG to see if weight reduction and diabetic improvement are sustainable.

METHODS

We conducted a prospective observational study on patients receiving LSG as an index stand-alone bariatric operation in our unit.

RESULTS

Between 2006 and 2014, there were 140 patients (91 females) aged 37.9 ± 10.5 years with a body mass index of 41.0 ± 7.0 kg/m(2). At 1-year (n = 123), 2-year (n = 99), 3-year (n = 77), 4-year (n = 52), and 5-year (n = 44) follow-ups, the mean percentages of excess weight loss (%EWL) were 70.5, 65.2, 60.2, 53.2, and 57.2%, respectively, while the corresponding proportions with failed weight loss (%EWL <30%) were 7.3, 9.1, 13.0, 25.0, and 22.7%. Weight regain (>25% rebound in %EWL) was evident with time as 0, 1.0, 11.6, 19.2, and 29.5% in the first 5-year follow-ups. In 65 patients with type 2 diabetes mellitus, remission (complete and partial) was achieved in 34.5% at 1-year, 52.7% at 3-year, and 70.6% at 5-year follow-ups. Proportions of patients having optimal glycemic control (HbA1c <7%) increased significantly from 26.2% preoperatively to 80.9% at the first year and maintained at 78.6% at the fifth year (P < 0.001).

CONCLUSIONS

LSG was effective in achieving substantial weight reduction and improved diabetic control for morbidly obese patients. Although weight regain was possible with time, majority of patients could maintain sustainable weight loss, diabetes remission, and glycemic improvement in the long run.

Effects of sleeve gastrectomy on insulin resistance

BACKGROUND AND AIM

Obesity is a major risk factor for the onset of insulin resistance (IR), hyperinsulinemia and type 2 diabetes mellitus (T2DM) Evidence data has proven that beyond important weight loss bariatric surgery especially Roux-en-Y gastric bypass (RYGB) and bilio-pancreatic diversion (BPD) leads to significant early reduction of insulinemia and of IR calculated through the homeostatic model assessment (HOMA-IR), independently of fat mass decrease. Sleeve gastrectomy (SG) is now used as a sole weight loss operation with good results. Therefore, the aim of the present study was to investigate the early changes of fasting blood glucose, insulin and HOMA-IR in a group of morbidly obese (MO) patients i.e. at 7, 30 and 90 days after SG.

METHODS

The study included 20 MO patients (7 male and 13 female) submitted to SG. Anthropometrical (weight, body mass index -BMI, percent excess BMI loss -%EBMIL) and biochemical (plasma glucose, insulin and calculated HOMA-IR ) evaluation were performed before and at 7, 30 and 90 days after SG. In addition, a second group of 10 normal weight healthy subjects with a BMI ranging form 19 kg/m(2) to 23.14 kg/m(2), matched for age and gender was investigated.

RESULTS

Plasma glucose (p=0.018), insulin (p=0.004) and HOMA-IR (p=0.006) values were statistically different between the studied groups. After surgery, at every follow-up point, there were statistically different weight and BMI mean values relative to the operation day (p<0.003). BMI, decreased at 7 days (estimated reduction=2.79; 95% CI:[2.12;3.45]), at 30 days (estimated reduction=5.65; 95% CI:[3.57;7.73]) and at 90 days (estimated reduction=10.88; 95% CI:[7.35;14.41]) respectively after SG. We noted a tendency toward statistical significant change of mean insulin values at 7 days after surgery (corrected p=0.075), no statistical change at 30 days (corrected p=0.327) and a significant change at 90 days (corrected p=0.027) after SG as compared to baseline. There was a significant change in mean values of HOMA-IR at 30 days (corrected p=0.009) and at 90 days (corrected p=0.021) after the operation day.

CONCLUSIONS

The present study showed important early changes consisting in reductions of mean values of plasma insulin and HOMA-IR after SG.

Subtotal Gastrectomy With Billroth II Anastomosis Is Associated With a Low Risk of Ischemic Stroke in Peptic Ulcer Disease Patients: A Nationwide Population-Based Study

Duodenal diversion can ameliorate lipid and glucose metabolism. We assessed the risk of stroke after subtotal gastrectomy with Billroth II anastomosis (SGBIIA) in peptic ulcer disease (PUD). We identified 6425 patients who received SGBIIA for PUD between 1998 and 2010 from the Taiwan National Health Insurance Research Database as the study cohort; we frequency-matched them with 25,602 randomly selected controls from the PUD population who did not receive SGBIIA according to age, sex, index year, and comorbidities including hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), and obesity. All patients were followed until the end of 2011 to determine the incidence of stroke. The incidence of stroke was lower in patients in the SGBIIA cohort than in those in the non-SGBIIA cohort (18.9 vs 22.9 per 1000 person-years, adjusted hazard ratio [aHR] 0.80, 95% confidence interval [CI] 0.72-0.89, P < 0.001). The risk of ischemic stroke (aHR 0.77, 95% CI 0.69-0.86, P < 0.001), rather than hemorrhagic stroke (aHR 1.00, 95% CI 0.78-1.28), was lower for the SGBIIA cohort than for the non-SGBIIA cohort according to the multivariable Cox proportional hazard regression analysis. The relative risk of ischemic stroke after SGBIIA was lower in men (aHR 0.77, 95% CI 0.69-0.86) than in women (aHR 0.80, 95% CI 0.65-0.99) and in patients aged ≥65 years (aHR 0.72, 95% CI 0.63-0.81) than in those of other age groups (≤49 years, aHR 0.82, 95% CI 0.48-1.39; 50-64 years, aHR 1.01, 95% CI 0.79-1.28). The relative risk of ischemic stroke after SGBIIA was also reduced in patients with comorbidities (aHR 0.84, 5% CI 0.75-0.95) rather than in those without comorbidities (aHR 0.81, 95% CI 0.59-1.12). SGBIIA is associated with a low risk of ischemic stroke for PUD patients, and its protective effect is prominent in men, patients aged ≥65 years, and those with comorbidities.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

[Outcomes, controversies and gastric volume after laparoscopic sleeve gastrectomy in the treatment of obesity]

BACKGROUND

Laparoscopic sleeve gastrectomy is a surgical procedure for the treatment of morbid obesity. However, there are still controversies regarding its efficiency in terms of weight reduction and incidence of complications. In this prospective study, the experience is presented of a referral centre for the treatment of morbid obesity with laparoscopic sleeve gastrectomy.

MATERIAL AND METHODS

A prospective study on 73 patients subjected to laparoscopic sleeve gastrectomy from February 2009 to September 2013. Patients were followed-up for a period of 12 months, evaluating the development of complications, reduction of gastric volume, and the weight loss associated with the surgery, as well as their impact on the improvement of comorbidities present at beginning of the study.

RESULTS

There was a statistically a significantly reduction between the preoperative body mass index (BMI) and the BMI at 12 months after laparoscopic sleeve gastrectomy (p < 0.001), despite there being an increase in the gastric volume during follow-up, measured at one month and 12 months after surgery (p < 0.001). Five patients (6.85%) had complications, with none of them serious and with no deaths in the whole series.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is a safe and effective technique for the treatment of morbid obesity. Its use is associated with a significant reduction in the presence of comorbidities associated with obesity. Multicentre studies with a longer period of monitoring are required to confirm the efficacy and safety of this surgical technique.

Treatment of obesity in 2015

Obesity is a major health priority in the United States, as well as globally. It is associated with multiple comorbidities and reduced life expectancy. Effective management of obesity involves producing an intervention plan tailored to the individual patient. Potential contributory factors to weight gain, including dietary habits, physical inactivity, associated medical conditions, and medications, should be identified and addressed. Lifestyle interventions comprising diet modification, physical activity, and behavior therapy are foundational to the management of obesity. Caloric restriction is the most important component in achieving weight loss through negative energy balance, whereas sustained physical activity is important in maintaining the weight loss. Adjunctive therapies in the form of pharmacotherapy and bariatric surgery are required in patients who do not achieve targeted weight loss and health goals with lifestyle interventions. Currently there are 3 drugs approved for long-term management of obesity, orlistat, phentermine/topiramate extended release, and lorcaserin, and there are 2 on the horizon, bupropion/naltrexone and liraglutide. Bariatric surgery is an effective strategy recognized to produce durable weight loss with amelioration of obesity-related comorbidities and should be considered a treatment option in eligible patients.

Effect of sleeve gastrectomy on type 2 diabetes as an alternative treatment modality to Roux-en-Y gastric bypass: systemic review and meta-analysis

BACKGROUND

Until recently, Roux-en-Y gastric bypass (RYGB) was the most frequently performed procedure in bariatric surgery. In the last decade, sleeve gastrectomy (SG) has emerged as a more popular, simpler, and less morbid form of bariatric surgery.

OBJECTIVES

This study compares the efficacy of SG and RYGB for the treatment of type 2 diabetes mellitus (T2D).

SETTING

Systemic review and meta-analysis.

METHODS

MEDLINE, EMBASE, and the Cochrane Library were searched for entries up to December 2013. Search terms included "Sleeve gastrectomy," "Gastric bypass," and "Type 2 diabetes mellitus." The chosen articles described both "Sleeve gastrectomy" and "Gastric bypass" and included over 1 year of follow-up data. Data analysis was performed with Review Manager 5.2 and SPSS version 20.

RESULTS

The data set is comprised of 3 retrospective clinical studies, 6 prospective clinical studies, and 2 randomized controlled trials (RCTs), which involved 429 patients in the SG group and 428 patients in the RYGB group. In nonrandomized clinical studies, SG displayed similar efficacy in remission of T2D compared with the standard RYGB. In the RCTs, SG had a lower effect than that of RYGB. T2D remission was not correlated with the percent of excess weight loss for either procedure.

CONCLUSIONS

Based on the current evidence, SG has a similar effect on T2D remission as RYGB.

Predictive factors of type 2 diabetes mellitus remission following bariatric surgery: a meta-analysis

BACKGROUND

Although a few studies have been reported on predictive factors of postoperative diabetes remission, the conclusions remain inconsistent. This meta-analysis aimed to assess the preoperative clinical factors for type 2 diabetes mellitus (T2DM) remission after bariatric surgery.

METHODS

The Cochrane Library, PubMed, MEDLINE, Embase, and CINAHL databases were searched. All human studies published in English between 1 January 1992 and 1 September 2013 reporting on the parameters of interest were included.

RESULTS

In total, 15 studies involving 1,753 bariatric surgery patients were selected. Analyses were performed separately for the parameters of interest. T2DM remission was observed to be negatively correlated with age, diabetes duration, insulin use, and HbA1c levels. Baseline body mass index (BMI) and C-peptide levels were positively associated with the remission rate in Asian patients. However, there was no significant association between gender and remission rate.

CONCLUSIONS

Patients with younger age, short diabetes duration, better glucose control, and better β cell function were more likely to achieve T2DM remission after bariatric surgery. However, further randomized controlled trials with uniform remission criteria should be conducted to provide more reliable evidence.

Is resected stomach volume related to weight loss after laparoscopic sleeve gastrectomy?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) was initially performed as the first stage of biliopancreatic diversion with duodenal switch for the treatment of super-obese or high-risk obese patients but is now most commonly performed as a standalone operation. The aim of this prospective study was to investigate outcomes after LSG according to resected stomach volume.

METHODS

Between May 2011 and April 2013, LSG was performed in 102 consecutive patients undergoing bariatric surgery. Two patients were excluded, and data from the remaining 100 patients were analyzed in this study. Patients were divided into three groups according to the following resected stomach volume: 700-1,200 mL (group A, n = 21), 1,200-1,700 mL (group B, n = 62), and >1,700 mL (group C, n = 17). Mean values were compared among the groups by analysis of variance.

RESULTS

The mean percentage excess body weight loss (%EBWL) at 3, 6, 12, and 24 months after surgery was 37.68 ± 10.97, 50.97 ± 13.59, 62.35 ± 11.31, and 67.59 ± 9.02 %, respectively. There were no significant differences in mean %EBWL among the three groups. Resected stomach volume was greater in patients with higher preoperative body mass index and was positively associated with resected stomach weight.

CONCLUSIONS

Mean %EBWL after LSG was not significantly different among three groups of patients divided according to resected stomach volume. Resected stomach volume was significantly greater in patients with higher preoperative body mass index.

Weight Loss and the Prevention and Treatment of Type 2 Diabetes Using Lifestyle Therapy, Pharmacotherapy, and Bariatric Surgery: Mechanisms of Action

Weight loss, whether achieved by lifestyle intervention, pharmacotherapy, or bariatric surgery, is highly effective as a primary interventional strategy in both the prevention and treatment of type 2 diabetes. In high-risk patients with prediabetes and/or metabolic syndrome, weight loss effectively prevents progression to type 2 diabetes mellitus (T2DM) and improves cardiovascular risk factors. These benefits are the result of improvements in insulin resistance, which is central to the pathophysiology of cardiometabolic disease. In patients with T2DM, weight loss improves glycemia, while reducing the need for conventional glucose-lowering medicines, by affecting all three processes that produce and sustain the hyperglycemic state, namely via increments in peripheral insulin sensitivity with improvements in insulin signal transduction at the cellular level, more robust insulin secretory responses, and reduced rates of hepatic glucose production. In both nondiabetic and diabetic subjects, hypocaloric feeding (e.g., treatment with very low-calorie diet or bariatric surgery) produces a rapid improvement in insulin sensitivity due to mobilization of fat from the intramyocellular, intrahepatocellular, and intra-abdominal compartments, and via a more long-term mechanism that correlates with the loss of total body fat. In diabetes, by improving glycemia, weight loss also enhances glucose homeostasis by reversing the defects in insulin action and secretion attributable to glucose toxicity. Regardless of the therapeutic approach, weight loss of ∼ 10 % maximally prevents future diabetes in patients with prediabetes or metabolic syndrome. In T2DM, greater degrees of weight loss lead to progressive improvements in glucose homeostasis. Therefore, when accompanied by greater weight loss, the metabolic benefits following bariatric surgery are generally more pronounced than those achieved following lifestyle and medical treatment. In addition, the mechanisms by which bariatric operations improve diabetes may include both weight-dependent and weight-independent mechanisms, and the latter may involve changes in gut hormones, bile acids, or gut microflora.

Rapid Reduction in Use of Antidiabetic Medication after Laparoscopic Sleeve Gastrectomy: The Newfoundland and Labrador Bariatric Surgery Cohort (BaSCo) Study

BACKGROUND

Patients who have undergone bariatric surgery generally need fewer medications as they experience improvement in, or even resolution of, various medical conditions, including type 2 diabetes mellitus, hypertension, and dyslipidemia. Published data on changes in medication use after laparoscopic sleeve gastrectomy, a type of bariatric surgery that is growing in popularity, are limited.

OBJECTIVE

To determine whether patients took fewer medications for management of type 2 diabetes, hypertension, and dyslipidemia after laparoscopic sleeve gastrectomy, relative to preprocedure medications.

METHODS

In this prospective, single-centre cohort study, a nurse practitioner used standard medication reconciliation and study data-extraction forms to interview adult patients who had undergone laparoscopic sleeve gastrectomy and determine their medication use and pertinent demographic data. The data were analyzed using generalized estimating equations and standard statistical software. Outcome measures included changes in the use of antidiabetic, antihypertensive, and antilipemic medications at 1, 3, and 6 months after the surgery.

RESULTS

A total of 65 patients who underwent laparoscopic sleeve gastrectomy between May 2011 and January 2014 met the study inclusion criteria. Before surgery, the 30 patients with type 2 diabetes were taking an average of 1.9 antidiabetic medications. One month after the procedure, 15 (50%) had discontinued all antidiabetic medications, with a further decline at 3 and 6 months (p < 0.001 at each time point). Among the patients who were taking antihypertensives (n = 48) and antilipemics (n = 33) before surgery, the decline in use occurred at a more modest rate, with 6 (12%) and 2 (6%), respectively, discontinuing these medication classes within 1 month, and 12 (25%) (p = 0.001) and 8 (24%) (p = 0.015) having discontinued by 6 months.

CONCLUSIONS

These findings suggest that patients with a history of type 2 diabetes mellitus, hypertension, and/or dyslipidemia who undergo laparoscopic sleeve gastrectomy are less likely to require disease-specific medications shortly after surgery.

Is type 2 diabetes really resolved after laparoscopic sleeve gastrectomy? Glucose variability studied by continuous glucose monitoring

The study was carried out on type 2 diabetic obese patients who underwent laparoscopic sleeve gastrectomy (LSG). Patients underwent regular glycemic controls throughout 3 years and all patients were defined cured from diabetes according to conventional criteria defined as normalization of fasting glucose levels and glycated hemoglobin in absence of antidiabetic therapy. After 3 years of follow-up, Continuous Glucose Monitoring (CGM) was performed in each patient to better clarify the remission of diabetes. In this study, we found that the diabetes resolution after LSG occurred in 40% of patients; in the other 60%, even if they showed a normal fasting glycemia and A1c, patients spent a lot of time in hyperglycemia. During the oral glucose tolerance test (OGTT), we found that 2 h postload glucose determinations revealed overt diabetes only in a small group of patients and might be insufficient to exclude the diagnosis of diabetes in the other patients who spent a lot of time in hyperglycemia, even if they showed a normal glycemia (<140 mg/dL) at 120 minutes OGTT. These interesting data could help clinicians to better individualize patients in which diabetes is not resolved and who could need more attention in order to prevent chronic complications of diabetes.

Short-term outcomes of sleeve gastrectomy for morbid obesity: does staple line reinforcement matter?

Background

Stand-alone laparoscopic sleeve gastrectomy (LSG) has been found to be effective in producing weight loss but few large, one-center LSG series have been reported. Gastric leakage from the staple line is a life-threatening complication of LSG, but there is controversy about whether buttressing the staple line with a reinforcement material will reduce leaks. We describe a single-center, 518-patient series of LSG procedures in which a synthetic buttressing material (GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement) was used in the most recently treated patients.

Methods

We retrospectively reviewed the medical records of all patients who underwent LSG in our unit between September 2007 and December 2011. Patients treated before August 2009 did not receive the staple line reinforcement material (n = 186), whereas all patients treated afterward did (n = 332).

Results

The percentages of excess weight loss in the 518 patients (mean age, 41 years; 82 % female; mean preoperative body mass index, 44 kg/m²) were 67 % (79 % follow-up rate) at 6 months postoperatively, 81 % (64 %) at 1 year, and 84 % (30 %) at 2 years. Type 2 diabetes resolved in 71 % of patients (91/128). Patients given reinforcement material had baseline characteristics similar to those in the no-reinforcement-material group, but had no postoperative staple line leaks or bleeding. The no-reinforcement group had three leaks (p = 0.045) and one case of bleeding.

Conclusions

LSG resulted in substantial short-term weight loss. Use of the bioabsorbable staple line reinforcement material may decrease leaks after LSG.

Effects of sleeve gastrectomy and gastric banding on the hypothalamic feeding center in an obese rat model

PURPOSE

Laparoscopic sleeve gastrectomy (SG) and gastric banding (GB) are popular bariatric procedures for treating morbid obesity. This study aimed to investigate changes in the hypothalamic feeding center after these surgeries in a diet-induced obese rat model.

METHODS

Obesity was induced in 60 Sprague-Dawley rats using a high-energy diet for 6 weeks. These rats were divided into four groups: the sham-operated (SO) control, pair-fed (PF) control, SG and GB groups. Six weeks after the surgery, metabolic parameters, the plasma levels of leptin, ghrelin, peptide YY (PYY) and glucagon-like peptide-1 (GLP-1) and the hypothalamic mRNA expressions of neuropeptide Y (NPY) and pro-opiomelanocortin (POMC) were measured.

RESULTS

Compared with those observed in the SO group, the body and fat tissue weights were significantly decreased and the metabolic parameters were significantly improved in the PF, SG and GB groups 6 weeks after surgery. The plasma ghrelin levels were significantly lower and the PYY and GLP-1 levels were significantly higher in the SG group than in the PF, GB and SO groups. Compared with that seen in the PF and GB groups, the hypothalamic mRNA expression of NPY was significantly lower and the expression of POMC was significantly higher in the SG group.

CONCLUSIONS

SG may affect the neurological pathway associated with appetite in the hypothalamus and thereby control ingestive behavior.

Laparoscopic Roux-en-Y Gastric Bypass versus Sleeve Gastrectomy for Obese Patients with Type 2 Diabetes: A Meta-analysis of Randomized Controlled Trials

We aimed to evaluate the efficacy and safety of laparoscopic Roux-en-Y gastric bypass versus sleeve gastrectomy for obese patients with Type 2 diabetes. We searched the Cochrane Library, PubMed, EMBASE, Google Scholar, and the Chinese Wan fang database up to October 2013. Randomized controlled trials regarding the efficacy and safety of laparoscopic gastric bypass versus sleeve gastrectomy for obese diabetic patients were included. Two review authors independently abstracted data and assessed the risk of bias. The mean difference and relative risk were estimated with 95 per cent confidence intervals. Four randomized controlled trials met inclusion criteria. There was no significant difference between gastric bypass and sleeve gastrectomy groups with regard to glycosylated hemoglobin (mean difference [MD], 0.41%; 95% confidence interval [CI], -0.09 to 0.91), fasting plasma glucose (standardized MD, 0.61 mg/mL; 95% CI, -0.10 to 1.32), the numbers of subjects using oral antihyperglycemic medications and insulin (relative rate [RR], 1.53; 95% CI, 0.45 to 5.24; RR, 1.44; 95% CI, 0.47 to 4.39, respectively), body weight (MD, 0.42 kg; 95% CI, -5.01 to 5.85), body mass index (MD, 0.85 kg/m2; 95% CI, 0.13 to 1.58), or waist circumference (MD, 1.59 cm; 95% CI, -3.02 to 6.19). However, cardiovascular risk was more significantly lessened in the gastric bypass group. Our meta-analysis demonstrated that compared with laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass offers equal efficacy for treatment of diabetes in obese patients but is associated with a significantly decreased cardiovascular risk.

Lipopolysaccharide and lipopolysaccharide-binding protein levels and their relationship to early metabolic improvement after bariatric surgery

BACKGROUND

Bariatric surgery usually results in metabolic improvements within a few days from intervention, but the underlying mechanism is not completely understood and may vary depending on the bariatric procedure. Lipopolysaccharides (LPS) from gut microbiota have been proposed as a triggering factor for the inflammatory state in obesity. Roux-en-Y Gastric Bypass (RYGB) leads to a LPS decrease in the medium-term.

OBJECTIVE

To analyze LPS and LPS-binding protein (LBP) in normoglycemic (NG) and diabetic morbidly obese patients in the short-term after 2 different bariatric surgery procedures.

SETTING

University Hospital, Spain.

METHODS

Fifty morbidly obese patients underwent bariatric surgery: 24 with sleeve gastrectomy (SG) and 26 with biliopancreatic diversion (BPD). Patients were classified according to their glycemic status as NG or prediabetic/diabetic. LPS and LBP levels and biochemical and anthropometric variables were determined before and at days 15 and 90 after surgery.

RESULTS

A significant LPS reduction was seen only in the prediabetic/diabetic patients at 90 days after SG. LBP levels rose at 15 days after BPD but at 90 days returned to baseline in both NG and prediabetic/diabetic patients. At 90 days after SG, LBP levels significantly decreased compared to baseline in NG and prediabetic/diabetic patients. After multivariate analysis only the change in BMI was independently associated with the change in LBP levels at 90 days. None of the changes in biochemical or anthropometrical variables were significantly associated with the changes in LPS levels at 15 days or 90 days.

CONCLUSION

This is the first study showing that the short-term LPS decrease after bariatric surgery depends on the surgical procedure used as well as on the previous glycemic status of the patient, with SG having the greatest short-term effect on LPS and LBP levels. LBP is closely related to anthropometric variables and may be an inflammatory marker in bariatric surgery patients.

Diabetes and weight in comparative studies of bariatric surgery vs conventional medical therapy: a systematic review and meta-analysis

We performed a meta-analysis of weight loss and remission of type 2 diabetes mellitus (T2DM) evaluated in randomized controlled trials (RCTs) and observational studies of bariatric surgery vs conventional medical therapy. English articles published through June 10, 2013 that compared bariatric surgery with conventional therapy and included T2DM endpoints with ≥12-month follow-up were systematically reviewed. Body mass index (BMI, in kilogram per square meter), glycated hemoglobin (HbA1C, in degree), and fasting plasma glucose (FPG, in milligram per deciliter) were analyzed by calculating weighted mean differences (WMDs) and pooled standardized mean differences and associated 95 % confidence intervals (95 % CI). Aggregated T2DM remission event data were analyzed by calculating the pooled odds ratio (POR) and 95 % CI. Random effects assumptions were applied throughout; I(2) ≥ 75.0 % was considered indicative of significant heterogeneity. Systematic review identified 512 articles: 47 duplicates were removed, 446 failed inclusion criteria (i.e., n < 10 per arm, animal studies, reviews, case reports, abstracts, and kin studies). Of 19 eligible articles, two not focused on diagnosed T2DM and one with insufficient T2DM data were excluded. In the final 16 included papers, 3,076 patients (mean BMI, 40.9; age, 47.0; 72.0 % female) underwent bariatric surgery; 3,055 (39.4; 48.6, 69.0 %) received conventional or no weight-loss therapy. In bariatric surgery vs conventional therapy groups, the mean 17.3 ± 5.7 month BMI WMD was 8.3 (7.0, 9.6; p < 0.001; I(2) = 91.8), HbA(1C) was 1.1 (0.6, 1.6; p < 0.001; I(2) = 91.9), and FPG, 24.9 (15.9, 33.9; p < 0.001; I(2) = 84.8), with significant differences favoring surgery. The overall T2DM remission rate for surgery vs conventional group was 63.5 vs 15.6 % (p < 0.001). The Peto summary POR was 9.8 (6.1, 15.9); inverse variance summary POR was 15.8 (7.9, 31.4). Of the included studies, 94.0 % demonstrated a significant statistical advantage favoring surgery. In a meta-analysis of 16 studies (5 RCTs) with 6,131 patients and mean 17.3-month follow-up, bariatric surgery was significantly more effective than conventional medical therapy in achieving weight loss, HbA(1C) and FPG reduction, and diabetes remission. The odds of bariatric surgery patients reaching T2DM remission ranged from 9.8 to 15.8 times the odds of patients treated with conventional therapy.