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Cohen R, Caravatto PP, Petry T. Metabolic Surgery for Type 2 Diabetes in Patients with a BMI of <35 kg/m(2): A Surgeon's Perspective. Obes Surg 2014; 23:809-18. [PMID: 23564465 DOI: 10.1007/s11695-013-0930-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Bariatric surgery was developed with the aim of weight reduction. Success was defined only by excess weight loss. Other indices of resolution of metabolic comorbidities were reported, but were mostly secondary. Several communications have reported that regardless of body mass index (BMI), complete or partial remission of type 2 diabetes mellitus (T2DM) is possible. These results mostly occur before weight loss, positioning metabolic surgery as a good tool for controlling the current T2DM epidemic. Medical treatment is evolving, but is expensive and not risk-free. Surgery aimed mainly at diseases such as diabetes and not weight loss are referred to as "metabolic surgery." Metabolic surgery has been proven to be safe and effective, and although more data are needed, it is unquestionable that a new discipline has been founded. Metabolic surgery can effectively treat T2DM in individuals with any BMI, including that below 35 kg/m(2).
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Affiliation(s)
- Ricardo Cohen
- The Center of Excellence for Metabolic and Bariatric Surgery, Hospital Oswaldo Cruz, São Paulo, Brazil.
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52
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Metabolic surgery: Quo Vadis? ACTA ACUST UNITED AC 2014; 61:35-46. [DOI: 10.1016/j.endonu.2013.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 04/22/2013] [Accepted: 04/24/2013] [Indexed: 01/06/2023]
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53
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Systematic review of laparoscopic adjustable gastric banding in patients with body mass index ≤35 kg/m2. Surg Obes Relat Dis 2014; 10:155-60. [DOI: 10.1016/j.soard.2013.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 03/06/2013] [Accepted: 05/12/2013] [Indexed: 01/22/2023]
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Lipidomic profiling before and after Roux-en-Y gastric bypass in obese patients with diabetes. THE PHARMACOGENOMICS JOURNAL 2013; 14:201-7. [PMID: 24365785 DOI: 10.1038/tpj.2013.42] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/05/2013] [Accepted: 11/12/2013] [Indexed: 01/11/2023]
Abstract
Bariatric surgery is a well-established approach to improve metabolic disease in morbidly obese patients with high cardiovascular risk. The post-operative normalization of lipid metabolism has a central role in the prevention of future cardiovascular events. The aim of the present study therefore was to characterize changes of plasma lipidomic patterns, consisting of 229 lipid species of 13 lipid classes, 3 months after Roux-en-Y gastric bypass (RYGB) in morbidly obese patients with and without diabetes. RYGB resulted in a 15-32% decrease of body mass index, which was associated with a significant reduction of total cholesterol (TC, -28.3%; P=0.02), LDL-cholesterol (LDL-C, -26.8%; P=0.03) and triglycerides (TGs, -63.0%; P=0.05) measured by routine clinical chemistry. HDL-cholesterol remained unchanged. The effect of RYGB on the plasma lipidomic profile was characterized by significant decreases of 87 lipid species from triacylglycerides (TAGs), cholesterol esters (CholEs), lysophosphatidylcholines (LPCs), phosphatidylcholines (PCs), phosphatidylethanolamine ethers (PEOs), phosphatidylinositols (PIs) and ceramides (Cers). The total of plasma lipid components exhibited a substantial decline of 32.6% and 66 lipid species showed a decrease by over 50%. A direct correlation with HbA1C values could be demonstrated for 24 individual lipid species (10 TAG, three CholE, two LPC, one lysophosphatidylcholine ethers (LPCO) (LPC ether), one PC, two phosphatidylcholine ethers (PCO) and five Cer). Notably, two lipid species (TAG 58:5 and PEO 40:5) were inversely correlated with HbA1C. LPCO, as single whole lipid class, was directly related to HbA1C. These data indicate that RYGB-induced modulation of lipidomic profiles provides important information about post-operative metabolic adaptations and might substantially contribute to improvements of glycemic control. These striking changes in the human plasma lipidome may explain acute, weight independent and long-term effects of RYGB on the cardiovascular system, mental status and immune regulation.
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Abstract
PURPOSE OF REVIEW Obesity is a rising epidemic, and it is projected that over 700 million people will be obese by 2015. As the number of people with morbid obesity rises, so will the number of bariatric procedures performed. The goal of this article is to review current surgical and endoscopic options for weight loss in morbidly obese patients including their efficacy and complications. RECENT FINDINGS New bariatric surgical techniques have been developed with the goals of maximizing weight loss and metabolic outcomes, while minimizing complications. In addition, there is a role for therapeutic endoscopy in treating obesity as well as managing bariatric surgical complications. As the metabolic effects of bariatric surgery are better elucidated, bariatric surgeries may provide a role in treatment of metabolic syndrome in mildly obese individuals. For those with insufficient weight loss, revisional bariatric surgeries have been performed with varying success. SUMMARY Bariatric surgery is an effective treatment for obesity and its comorbidities. Several bariatric surgeries are available, and a multidisciplinary approach is recommended for choosing the best procedure for the appropriate candidate, along with providing long-term follow-up care to maximize outcome.
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Hofmann B, Hjelmesæth J, Søvik TT. Moral challenges with surgical treatment of type 2 diabetes. J Diabetes Complications 2013; 27:597-603. [PMID: 24028746 DOI: 10.1016/j.jdiacomp.2013.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 12/27/2022]
Abstract
AIM To review the most important moral challenges following from the widespread use of bariatric surgery for type 2 diabetes for patients with BMI <35kg/m(2), although high quality evidence for its short and long term effectiveness and safety is limited. METHODS Extensive literature search to identify and analyze morally relevant issues. A question based method in ethics was applied to facilitate assessment and decision making. RESULTS Several important moral issues were identified: assessing and informing about safety, patient outcomes, and stakeholder interests; acquiring valid informed consent; defining and selecting outcome measures; stigmatization and discrimination of the patient group, as well as providing just distribution of health care. The main sources of these challenges are lack of high quality evidence, disagreement on clinical indications and endpoints, and the disciplining of human behavior by surgical interventions. CONCLUSION A lack of high quality evidence on the effect of bariatric surgery for the treatment of T2DM in patients with BMI<35/kg/m(2) poses a wide variety of moral challenges, which are important for decisions on the individual patient level, on the management level, and on the health policy making level. Strong preferences among surgeons and patients may hamper high quality research.
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Affiliation(s)
- Bjørn Hofmann
- Department of Health, Technology and Society, University College of Gjøvik, Norway; Center for Medical Ethics, University of Oslo, Norway.
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Saad F, Haider A, Doros G, Traish A. Long-term treatment of hypogonadal men with testosterone produces substantial and sustained weight loss. Obesity (Silver Spring) 2013; 21:1975-81. [PMID: 23512691 DOI: 10.1002/oby.20407] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/21/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study analyzed the effects of normalization of serum testosterone (T) levels on anthropometric parameters in hypogonadal men. DESIGN AND METHODS Open-label, single-center, cumulative, prospective registry study of 255 men (aged 33-69 years, mean 58.02 ± 6.30 years), with T levels below 12.13 nmol/L (mean: 9.93±1.38). 215 men for at least 2 years, 182 for 3 years, 148 for 4, and 116 for at least 5 years were studied. They received parenteral T undecanoate 1,000 mg/12 weeks after an initial interval of 6 weeks. RESULTS Body weight (BW) decreased from 106.22 ± 16.93 kg to 90.07 ± 9.51 kg. Waist circumference (WC) reduced from 107.24 ± 9.14 cm to 98.46 ± 7.39 cm. BMI (m/kg(2) ) declined from 33.9 ± 5.51 m/kg(2) to 29.13 ± 3.09 m/kg(2) . All parameters examined were statistically significant with P < 0.0001 versus baseline and versus the previous year over 5 years indicating a continuous weight loss over the full observation period. The mean per cent weight loss after 1 year was 4.16 ± 0.31%, after 2 years 7.54 ± 0.32%, after 3 years 9.23 ± 0.33%, after 4 years 11.42 ± 0.35% and after 5 years 13.57 ± 0.37%. CONCLUSIONS In an uncontrolled, observational cohort, normalizing serum T to normal physiological levels produced consistent loss of BW, WC, and BMI. These improvements were progressive over the full 5 years of the study.
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Affiliation(s)
- Farid Saad
- Bayer Pharma, Global Medical Affairs Andrology, Berlin, Germany and Gulf Medical University School of Medicine, Ajman, UAE
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58
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Cohen R, Caravatto PP, Petry T. Surgery for Diabetes. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0023-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Pai JK, Cahill LE, Hu FB, Rexrode KM, Manson JE, Rimm EB. Hemoglobin a1c is associated with increased risk of incident coronary heart disease among apparently healthy, nondiabetic men and women. J Am Heart Assoc 2013; 2:e000077. [PMID: 23537807 PMCID: PMC3647270 DOI: 10.1161/jaha.112.000077] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 02/06/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hemoglobin A1c (HbA1c), a time-integrated marker of glycemic control, predicts risk of coronary heart disease (CHD) among diabetics. Few studies have examined HbA1c and risk of CHD among women and men without clinically elevated levels or previously diagnosed diabetes. METHODS AND RESULTS We conducted parallel nested case-control studies among women (Nurses' Health Study) and men (Health Professionals Follow-up Study). During 14 and 10 years of follow-up, 468 women and 454 men developed incident nonfatal myocardial infarction (MI) and fatal CHD. Controls were matched 2:1 based on age, smoking, and date of blood draw. For these analyses, participants with a history of diabetes or HbA1c levels ≥6.5% at baseline were excluded. Compared with HbA1c of 5.0% to <5.5%, those with an HbA1c of 6.0% to <6.5% had a multivariable-adjusted relative risk (RR) of CHD of 1.90 (95% CI 1.11 to 3.25) in women and 1.81 (95% CI 1.09 to 3.03) in men. The pooled RR of CHD was 1.29 (95% CI 1.11 to 1.50) for every 0.5%-increment increase in HbA1c levels and 1.67 (95% CI 1.23 to 2.25) for every 1%-increment increase, with the risk plateauing around 5.0%. Furthermore, participants with HbA1c levels between 6.0% and <6.5% and C-reactive protein levels >3.0 mg/L had a 2.5-fold higher risk of CHD compared with participants in the lowest categories of both biomarkers. CONCLUSIONS Our findings suggest that HbA1c is associated with CHD risk among apparently healthy, nondiabetic women and men and may be an important early clinical marker of disease risk.
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Affiliation(s)
- Jennifer K. Pai
- Department of Epidemiology, Harvard School of Public Health, Boston, MA (J.K.P., F.B.H., J.A.E.M., E.B.R.)
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.K.P., F.B.H., E.B.R.)
| | - Leah E. Cahill
- Department of Nutrition, Harvard School of Public Health, Boston, MA (L.E.C., F.B.H., E.B.R.)
| | - Frank B. Hu
- Department of Epidemiology, Harvard School of Public Health, Boston, MA (J.K.P., F.B.H., J.A.E.M., E.B.R.)
- Department of Nutrition, Harvard School of Public Health, Boston, MA (L.E.C., F.B.H., E.B.R.)
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.K.P., F.B.H., E.B.R.)
| | - Kathryn M. Rexrode
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (K.M.R., J.A.E.M.)
| | - JoAnn E. Manson
- Department of Epidemiology, Harvard School of Public Health, Boston, MA (J.K.P., F.B.H., J.A.E.M., E.B.R.)
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (K.M.R., J.A.E.M.)
| | - Eric B. Rimm
- Department of Epidemiology, Harvard School of Public Health, Boston, MA (J.K.P., F.B.H., J.A.E.M., E.B.R.)
- Department of Nutrition, Harvard School of Public Health, Boston, MA (L.E.C., F.B.H., E.B.R.)
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.K.P., F.B.H., E.B.R.)
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Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring) 2013; 21 Suppl 1:S1-27. [PMID: 23529939 PMCID: PMC4142593 DOI: 10.1002/oby.20461] [Citation(s) in RCA: 740] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 12/27/2012] [Indexed: 02/06/2023]
Abstract
The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Endocr Pract 2013; 19:337-72. [PMID: 23529351 PMCID: PMC4140628 DOI: 10.4158/ep12437.gl] [Citation(s) in RCA: 276] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis 2013; 9:159-91. [PMID: 23537696 DOI: 10.1016/j.soard.2012.12.010] [Citation(s) in RCA: 426] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 12/27/2012] [Indexed: 02/06/2023]
Abstract
The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Abstract
Bariatric surgery managing/preventing complications of severe overweight is nowadays widely accepted as a mainstay in the treatment of morbid obesity. Its role is particularly important in type 2 diabetes developing on the base of long-standing significant overweight. The glycemic control improves within days-weeks after these surgeries, when weight loss and reduction of the visceral fat mass is barely detectable. This short term effect is probably due to an increased secretion of glucagon-like peptide and, as a consequence, an improvement in hepatic insulin sensitivity as well as the whole body glucose uptake. Besides the prolonged glucagon-like peptide effects, the favourable long term effect of these operations - lasting for 10 years even after surgery - is the decrease of visceral fat mass and elimination of harmful influence of cytokines produced by the fatty tissue. The article overviews the metabolic effects of these procedures, their undoubted advantages and potential risks.
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Affiliation(s)
- Gábor Winkler
- Szent János Kórház II. Belgyógyászat-Diabetológia Budapest.
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64
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Van Gaal LF, De Block CEM. Bariatric surgery to treat type 2 diabetes: what is the recent evidence? Curr Opin Endocrinol Diabetes Obes 2012; 19:352-8. [PMID: 22895359 DOI: 10.1097/med.0b013e328357f0e0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW To critically discuss the strengths and shortcomings of recent progress achieved with bariatric surgery in patients with type 2 diabetes mellitus (T2DM), focussing on efficacy aspects (remission of diabetes and cardiovascular comorbidities). Despite an increasing armamentarium of pharmacotherapeutics to overcome several challenges, only 10% of T2DM patients achieve a composite goal of HbA1c, blood pressure and lipids. Bariatric surgery has emerged as a solution to these challenges in morbid obesity. Whether the same advantages can be translated into T2DM remains a matter of debate, certainly regarding safety, durability of diabetes recovery and long-term outcome. RECENT FINDINGS Bariatric surgery in T2DM patients with a BMI of at least 35 kg/m(2) has been shown to result in a 56% excess body weight loss, resolution of hypertension in 62%, amelioration of dyslipidaemia in greater than 70% and diabetes remission in 57-95%, depending on the type of surgery and the definition of diabetes resolution. These impressive results, and the fact that diabetes recovery often occurs before prominent weight loss is evident, have urged bariatric surgeons to consider surgical procedures as a valuable approach for diabetes control and diabetes remission in patients with a BMI ranging between 30 and 35 kg/m(2). SUMMARY Bariatric surgery is emerging as a valid option to treat T2DM, improving glycaemia and cardiovascular risk factors. However, there needs to be an agreed definition of resolution of diabetes in future studies and long-term efficacy is to be proven. For now, the challenge is to determine how to offer bariatric surgery in a responsible fashion.
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Affiliation(s)
- Luc F Van Gaal
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium.
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65
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Bariatric surgery in class I obesity (body mass index 30-35 kg/m²). Surg Obes Relat Dis 2012; 9:e1-10. [PMID: 23265765 DOI: 10.1016/j.soard.2012.09.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 09/13/2012] [Indexed: 01/18/2023]
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Jurowich C, Thalheimer A, Hartmann D, Bender G, Seyfried F, Germer CT, Wichelmann C. Improvement of Type 2 Diabetes Mellitus (T2DM) After Bariatric Surgery—Who Fails in the Early Postoperative Course? Obes Surg 2012; 22:1521-6. [DOI: 10.1007/s11695-012-0676-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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