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Piché MÈ, Auclair A, Harvey J, Marceau S, Poirier P. How to choose and use bariatric surgery in 2015. Can J Cardiol 2014; 31:153-66. [PMID: 25661550 DOI: 10.1016/j.cjca.2014.12.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 01/01/2023] Open
Abstract
Severe obesity is associated with increased morbidity and mortality and represents a major health care problem with increasing incidence worldwide. Bariatric surgery, through its efficacy and improved safety, is emerging as an important available treatment for patients with severe obesity. Classically, bariatric surgery has been described as either a restrictive or a hybrid surgery, which is a combination of restriction and malabsorption. For most severely obese patients, bariatric surgery results in the remission of major obesity-related comorbidities including type 2 diabetes mellitus, sleep apnea, hypertension, and dyslipidemia. Thus, bariatric surgery reduces cardiovascular risk burden, and overall mortality risk. Early complications (< 30 days) after bariatric surgery were reported to be < 10% and tend to be lower in restrictive surgeries compared with hybrid surgeries. Most common early complications reported are gastric and anastomosis leak (1.6%-5.1%), bleeding (0.5%-3.5%), and pulmonary embolism (0.2%-1%). Long-term complications (> 30 days) might differ depending on the type of bariatric surgery. According to the type of surgery and the type of study, the 30-day operative mortality rates differ from 0.1% to 1.2%. Studies on postoperative outcomes, investigations on weight loss physiology, and mechanism of action after bariatric surgery provide a better understanding of the bariatric surgery metabolic benefits. In this article, we present an overview of bariatric procedures with their effects, including risks and benefits, on the severely obese patients' health. It provides evidence to support surgical treatment of severe obesity to achieve cardiovascular disease risk reduction in severely obese patients.
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Affiliation(s)
- Marie-Ève Piché
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - Audrey Auclair
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Pharmacy, Laval University, Québec, Québec, Canada
| | - Jany Harvey
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Pharmacy, Laval University, Québec, Québec, Canada
| | - Simon Marceau
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - Paul Poirier
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada; Faculty of Pharmacy, Laval University, Québec, Québec, Canada.
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Nam SJ, Chun HJ, Lee D, Song Y, Kim SH, Lee JM, Yoo IK, Choi HS, Kim ES, Keum B, Jeen YT, Lee HS. Endoscopic 3D Stomach Reconstruction for Tailored Bariatric Treatment. Bariatr Surg Pract Patient Care 2014. [DOI: 10.1089/bari.2014.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Seung-Joo Nam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hoon Jai Chun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Dokwan Lee
- Department of Mechanical Engineering, Korea University, Seoul, Republic of Korea
| | - Yongnam Song
- Department of Mechanical Engineering, Korea University, Seoul, Republic of Korea
| | - Seung Han Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - In Kyung Yoo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyuk Soon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Eun Sun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Bora Keum
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yoon Tae Jeen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hong Sik Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
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Sala PC, Torrinhas RS, Giannella-Neto D, Waitzberg DL. Relationship between gut hormones and glucose homeostasis after bariatric surgery. Diabetol Metab Syndr 2014; 6:87. [PMID: 25152774 PMCID: PMC4141947 DOI: 10.1186/1758-5996-6-87] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/06/2014] [Indexed: 12/18/2022] Open
Abstract
Type 2 diabetes mellitus (T2D) is emerging as a worldwide public health problem, and is mainly associated with an increased incidence of obesity. Bariatric surgery is currently considered the most effective treatment for severely obese patients. After bariatric surgery, T2D patients have shown a significant improvement in glycemic control, even before substantial weight loss and often discontinuation of medication for diabetes control. A central role for enteroendocrine cells from the epithelium of the gastrointestinal tract has been speculated in this postoperative phenomenon. These cells produce and secrete polypeptides - gut hormones - that are associated with regulating energy intake and glucose homeostasis through modulation of peripheral target organs, including the endocrine pancreas. This article reviews and discusses the biological actions of the gut hormones ghrelin, cholecystokinin, incretins, enteroglucagon, and Peptide YY, all of which were recently identified as potential candidates for mediators of glycemic control after bariatric surgery. In conclusion, current data reinforce the hypothesis that T2D reversion after bariatric surgery may be related to glycemic homeostasis developed by the intestine.
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Affiliation(s)
- Priscila Campos Sala
- />Medical School, Department of Gastroenterology, Digestive Surgery Discipline (LIM 35), University of São Paulo, Av. Dr. Arnaldo, 455, Cerqueira César, CEP: 01246-903, São Paulo, Brazil
| | - Raquel Susana Torrinhas
- />Medical School, Department of Gastroenterology, Digestive Surgery Discipline (LIM 35), University of São Paulo, Av. Dr. Arnaldo, 455, Cerqueira César, CEP: 01246-903, São Paulo, Brazil
| | | | - Dan Linetzky Waitzberg
- />Medical School, Department of Gastroenterology, Digestive Surgery Discipline (LIM 35), University of São Paulo, Av. Dr. Arnaldo, 455, Cerqueira César, CEP: 01246-903, São Paulo, Brazil
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Chen X, Huang Z, Ran W, Liao G, Zha L, Wang Z. Type 2 diabetes mellitus control and atherosclerosis prevention in a non-obese rat model using duodenal-jejunal bypass. Exp Ther Med 2014; 8:856-862. [PMID: 25120614 PMCID: PMC4113651 DOI: 10.3892/etm.2014.1832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/02/2014] [Indexed: 01/06/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a prevalent disease worldwide and during its conventional treatment, vascular complications remain unavoidable. Roux-en-Y gastric bypass (GBP) is able to induce the remission of T2DM. However, studies of duodenal-jejunal bypass (DJB), a modified procedure of GBP, are being carried out to investigate its ability to induce the remission of T2DM and protect the aorta from atherosclerosis. The present study aimed to investigate the effect of DJB on the rate of T2DM remission and the prevention of atherosclerosis in the aorta in rats with streptozotocin-induced diabetes without obesity, and to explore the mechanism of DJB in protecting the aorta from atherosclerosis. A T2DM rat model was established with a high-fat diet and low-dose streptozotocin. Surgery was performed to analyze its effects on glucose homeostasis, lipid metabolism, inflammation and pathological changes. Furthermore, changes in c-jun NH2-terminal kinase 1 (JNK1) and inhibitor of κB kinase (IKKβ) genes in the aorta following DJB surgery were examined. Levels of blood glucose, lipids, insulin and tumor necrosis factor (TNF)-α were significantly elevated in the T2DM diabetic model compared with the non-diabetic control. A gradual recovery was observed in the DJB group following surgery. Foam cells and atherosclerotic plaques appeared in the ascending aortic tissue in the sham-surgery and T2DM groups, whereas only slight lesions were observed in the DJB group. The expression levels of JNK1 and IKKβ genes in the aorta were significantly increased in the sham-operated and T2DM groups compared with those in the DJB and normal control groups. The present study demonstrated that DJB caused remission of T2DM without weight loss in non-obese rats. Thus, DJB may delay or prevent the occurrence and development of atherosclerosis in the aorta and this may occur through the JNK1 and nuclear factor κB (NF-κB) signaling pathways.
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Affiliation(s)
- Xuan Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Zhen Huang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Wenhua Ran
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Gang Liao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Lang Zha
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Ziwei Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
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Effects of bariatric surgery on HDL structure and functionality: results from a prospective trial. J Clin Lipidol 2014; 8:408-17. [PMID: 25110222 DOI: 10.1016/j.jacl.2014.05.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 04/11/2014] [Accepted: 05/06/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND In addition to high-density lipoprotein cholesterol (HDL-C) levels, HDL quality appears also very important for atheroprotection. Obese patients with metabolic syndrome have significantly reduced HDL-C levels and are usually at increased risk for coronary heart disease. Despite that weight loss benefits these patients, its effects on HDL quality and functionality is currently poorly studied. OBJECTIVES We investigated how rapid weight loss affects HDL structure and its antioxidant potential in patients undergoing a malabsorptive bariatric procedure. METHODS Fasting plasma samples were collected the day before and 6 months after the bariatric procedure from 20 morbidly obese patients with body mass index >50, then HDL was isolated and analyzed by biochemical techniques. RESULTS We report a dramatic alteration in the apolipoprotein ratio of HDL that was accompanied by the presence of more mature HDL subspecies and a concomitant increase in the antioxidant potential of HDL. Interestingly, our obese cohort could be distinguished into 2 subgroups. In 35% of patients (n = 7), HDL before surgery had barely detectable apolipoprotein (apo) A-I and apoCIII, and the vast majority of their HDL cholesterol was packed in apoE-containing HDL particles. In the remaining 65% of patients (n = 13), HDL before surgery contained high levels of apoA-I and apoCIII, in addition to apoE. In both subgroups, surgical weight loss resulted in a switch from apoE to apoA-I-containing HDL. CONCLUSIONS Rapid weight loss exerts a significant improvement in HDL structure and functionality that may contribute to the documented beneficial effect of malabsorptive bariatric procedures on cardiovascular health.
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Lannoo M, Dillemans B. Laparoscopy for primary and secondary bariatric procedures. Best Pract Res Clin Gastroenterol 2014; 28:159-73. [PMID: 24485263 DOI: 10.1016/j.bpg.2013.11.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 11/13/2013] [Accepted: 11/23/2013] [Indexed: 01/31/2023]
Abstract
Recently obesity has been defined as a disease and has turned bariatric surgery into a part of a chronic illness management. Obesity induces several comorbidities leading to cardiovascular disease and mortality. The effects of bariatric surgery on these comorbidities used to be classified as weight-loss induced. However bariatric surgery has recently been termed metabolic surgery because of the suspected direct, weight loss independent effect of bariatric procedures on the physiopathological mechanisms causing excess fat storage and insulin resistance. This review describes the standard procedures commonly performed and their specific outcomes on metabolic diseases in order to work towards more patient tailored treatment of obesity and to reduce side effects. Furthermore this review focuses on gaps in understanding the pathogenesis of obesity and its treatment with bariatric surgery. Surgery failures as well as new techniques are discussed and evaluated.
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Affiliation(s)
- Matthias Lannoo
- Department of Abdominal Surgery, University Hospitals, Leuven, Belgium.
| | - Bruno Dillemans
- Department of Abdominal Surgery, AZ Sint Jan, Bruges, Belgium.
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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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Patel RT, Shukla AP, Ahn SM, Moreira M, Rubino F. Surgical control of obesity and diabetes: the role of intestinal vs. gastric mechanisms in the regulation of body weight and glucose homeostasis. Obesity (Silver Spring) 2014; 22:159-69. [PMID: 23512969 DOI: 10.1002/oby.20441] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 02/18/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To elucidate the specific role of gastric vs. intestinal manipulations in the regulation of body weight and glucose homeostasis. DESIGN AND METHODS The effects of intestinal bypass alone (duodenal-jejunal bypass -DJB) and gastric resection alone (SG) in Zucker Diabetic Fatty (ZDF) rats were compared. Additional animals underwent a combination procedure (SG + DJB). Outcome measures included changes in weight, food intake (FI), oral glucose tolerance (GT) and gut hormones. RESULTS DJB did not substantially affect weight and FI, whereas SG significantly reduced weight gain and food consumption. DJB rats showed weight-independent improvement in GT, which improved less after SG. Furthermore, SG significantly suppressed plasma ghrelin and increased insulin, glucagon like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide and peptide YY response to oral glucose whereas DJB had no effects on postprandial levels of these hormones. DJB restored postprandial glucagon suppression in diabetic rats whereas SG did not affect glucagon response. The combination procedure (SG + DJB) induced greater weight loss and better GT than SG alone without reducing food intake further. CONCLUSIONS These findings reveal a dominant role of the stomach in the regulation of body weight and incretin response to oral glucose whereas intestinal bypass primarily affects glucose homeostasis by a weight-, insulin- and incretin-independent mechanism.
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Affiliation(s)
- Rajesh T Patel
- Section of GI Metabolic Surgery, Diabetes Surgery Center, Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
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Ties JS, Zlabek JA, Kallies KJ, Al-Hamadini M, Kothari SN. The Effect of Laparoscopic Gastric Bypass on Dyslipidemia in Severely Obese Patients: a 5-Year Follow-up Analysis. Obes Surg 2013; 24:549-53. [DOI: 10.1007/s11695-013-1120-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Kim MJ, Park HK, Byun DW, Suh KI, Hur KY. Incretin levels 1 month after laparoscopic single anastomosis gastric bypass surgery in non-morbid obese type 2 diabetes patients. Asian J Surg 2013; 37:130-7. [PMID: 24210541 DOI: 10.1016/j.asjsur.2013.09.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 09/13/2013] [Accepted: 09/23/2013] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Bariatric surgery is an efficient procedure for the remission of type 2 diabetes (T2DM) from morbid obesity. However, in Asian countries, the mean body mass index (BMI) of T2DM patients is about 25 kg/m(2). Various data on patients undergoing gastric bypass surgery suggest that the control of T2DM after surgery occurs rapidly. We hypothesized that even in nonobese patients with T2DM, the levels of incretin and insulin changed along with the improvement of T2DM as a consequence of the gastric bypass. MATERIALS AND METHODS From March to December 2011, 12 nonobese patients (mean BMI; 26.2 kg/m(2)) with poorly-controlled [mean glycated hemoglobin (HbA1C); 9.5%] diabetes underwent gastric bypass surgery. Values related to diabetes, including incretin [gastric inhibitory peptide (GIP) and glucagon-like peptide-1 (GLP-1)] levels were measured before and 1 month after surgery. All values were measured in response to a 75 g oral glucose tolerance test (OGTT). RESULTS On average, the BMI decreased by 2.1 ± 0.7 kg/m(2). Mean HbA1C level decreased by 1.6 ± 2%. Oral glucose-stimulated insulin levels increased and GLP-1 levels also increased significantly. Oral glucose-stimulated GIP levels decreased sharply. CONCLUSION Soon after gastric bypass in nonobese T2DM patients, control of T2DM is achieved. The incretin release after oral glucose is improved. This could be a consequence of changes of the enteroinsular axis, particularly in the incretins.
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Affiliation(s)
- Myung Jin Kim
- Department of Surgery, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Hyeong Kyu Park
- Department of Endocrinology, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Dong Won Byun
- Department of Endocrinology, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Kyo Il Suh
- Department of Endocrinology, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Kyung Yul Hur
- Department of Surgery, Soonchunhyang University College of Medicine, Seoul, South Korea.
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Våge V, Nilsen RM, Berstad A, Behme J, Sletteskog N, Gåsdal R, Laukeland C, Mellgren G. Predictors for remission of major components of the metabolic syndrome after biliopancreatic diversion with duodenal switch (BPDDS). Obes Surg 2013; 23:80-6. [PMID: 23011463 DOI: 10.1007/s11695-012-0775-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Metabolic surgery causes the remission of type 2 diabetes mellitus (T2DM), hypertension, and hyperlipidemia to varying degrees, depending on the patient characteristics and the surgical procedure. The aim of this study was to find predictors for the remission of T2DM and hypertension after biliopancreatic diversion with duodenal switch (BPDDS). METHODS Eighty patients with T2DM were followed up for 2 years or more after BPDDS, and changes in body weight and metabolic status were noted. Remission was defined as fasting glucose <7 mmol/l with HbA1C <6.5 %, blood pressure <140/90 mmHg, and low-density lipoprotein (LDL) <2.6 mmol without the use of medication. RESULTS Preoperatively, the mean age was 44 years, body mass index (BMI) was 48 kg/m(2), and duration of diabetes was 5 years. Of the 80 patients, 38 patients were using insulin, 48 patients were using antihypertensives, and 38 patients were using a lipid-lowering drug. Five percent of the patients had recommended levels for HbA1C, blood pressure, and LDL prior to the operation. The remission rate at 2 years was 94 % for T2DM, 54 % for hypertension, and 86 % for LDL hyperlipidemia. Preoperative predictors for nonremission of T2DM were a higher BMI, insulin usage, and low insulin C-peptide, and for hypertension, older age and more severe hypertension. Postoperative weight loss was important for both. CONCLUSIONS Surgical intervention with BPDDS is an effective treatment of T2DM, hypertension, and hyperlipidemia. The duration of T2DM and age of the patient are the most important preoperative predictors for the remission of T2DM and hypertension, respectively.
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Affiliation(s)
- Villy Våge
- Department of Surgery, Førde Central Hospital, 6807 Førde, Norway.
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Differential methylation in glucoregulatory genes of offspring born before vs. after maternal gastrointestinal bypass surgery. Proc Natl Acad Sci U S A 2013; 110:11439-44. [PMID: 23716672 DOI: 10.1073/pnas.1216959110] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Obesity and overnutrition during pregnancy affect fetal programming of adult disease. Children born after maternal bariatric gastrointestinal bypass surgery (AMS) are less obese and exhibit improved cardiometabolic risk profiles carried into adulthood compared with siblings born before maternal surgery (BMS). This study was designed to analyze the impact of maternal weight loss surgery on methylation levels of genes involved in cardiometabolic pathways in BMS and AMS offspring. Differential methylation analysis between a sibling cohort of 25 BMS and 25 AMS (2-25 y-old) offspring from 20 mothers was conducted to identify biological functions and pathways potentially involved in the improved cardiometabolic profile found in AMS compared with BMS offspring. Links between gene methylation and expression levels were assessed by correlating genomic findings with plasma markers of insulin resistance (fasting insulin and homeostatic model of insulin resistance). A total of 5,698 genes were differentially methylated between BMS and AMS siblings, exhibiting a preponderance of glucoregulatory, inflammatory, and vascular disease genes. Statistically significant correlations between gene methylation levels and gene expression and plasma markers of insulin resistance were consistent with metabolic improvements in AMS offspring, reflected in genes involved in diabetes-related cardiometabolic pathways. This unique clinical study demonstrates that effective treatment of a maternal phenotype is durably detectable in the methylome and transcriptome of subsequent offspring.
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Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg 2013; 257:87-94. [PMID: 23235396 DOI: 10.1097/sla.0b013e31827b6c02] [Citation(s) in RCA: 352] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To describe the long-term outcomes after laparoscopic adjustable gastric banding (LAGB) and compare these with the published literature on bariatric surgery. BACKGROUND Because obesity is a chronic disease, any proposed obesity treatment should be expected to demonstrate long-term durability to be considered effective. Yet for bariatric surgery, few long-term weight loss data are available. We report our 15-year follow-up data after LAGB and provide a systematic review of the peer-reviewed literature for weight loss at 10 years or more after bariatric surgical procedures. METHODS We performed a prospective longitudinal cohort study of LAGB patients using an electronic database system (LapBase) to track progress, measure weight changes, and document revisional procedures. The evolution of the LAGB procedure was recognized, and revisional rates for 3 separate periods between September 1994 and December 2011 were described. In addition, we performed a systematic review of the peer-reviewed published literature collecting all reports that included weight loss data at or beyond 10 years. RESULTS A total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m, were treated by laparoscopic adjustable gastric band placement between September 1994 and December 2011. Seven hundred fourteen patients had completed at least 10 years of follow-up. Follow-up was intact in 81% of patients overall and 78% of those beyond 10 years. There was no perioperative mortality for the primary placement or for any revisional procedures. There was 47.1% of excess weight loss (% EWL) at 15 years [n = 54; 95% confidence interval (CI) = 8.3] and 62% EWL at 16 years (n = 14; 95% CI = 13.6). There was a mean of 47.0% EWL (n = 714; 95% CI = 1.3) for all patients who were at or beyond 10 years follow-up. Revisional procedures were performed for proximal enlargement (26%), erosion (3.4%), and port and tubing problems (21%). The band was explanted in 5.6%. The need for revision decreased as the technique evolved, with 40% revision rate for proximal gastric enlargements in the first 10 years, reducing to 6.4% in the past 5 years. The revision group showed a similar weight loss to the overall group beyond 10 years. The systematic review of all bariatric procedures with 10 or more years of follow-up showed greater than 50% EWL for all current procedures. The weighted mean at maximum follow-up for LAGB was 54.2% EWL and for Roux-en-Y gastric bypass was 54.0% EWL. CONCLUSIONS The LAGB study from 1 center demonstrates a durable weight loss with 47% EWL maintained to 15 years. This weight loss occurred regardless of whether any revisional procedures were needed. A systematic review shows substantial and similar long-term weight losses for LAGB and other bariatric procedures.
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Busetto L, De Stefano F, Pigozzo S, Segato G, De Luca M, Favretti F. Long-term cardiovascular risk and coronary events in morbidly obese patients treated with laparoscopic gastric banding. Surg Obes Relat Dis 2013; 10:112-20. [PMID: 23791451 DOI: 10.1016/j.soard.2013.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 02/27/2013] [Accepted: 03/23/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Long-term studies reporting the effects of bariatric surgery on cardiovascular risk factors and events are scarce. The aim of this study was to analyze reduction of multiple cardiovascular risk factors and rates of coronary events in morbidly obese patients treated with bariatric surgery and with>10 years of follow-up. METHODS This was a prospective uncontrolled study with laparoscopic adjustable gastric banding. Cardiovascular risk factors (fasting glucose, total cholesterol, HDL-C, triglycerides, blood pressure) have been previously determined both at surgery and 12-18 months after in 650 patients treated with laparoscopic adjustable gastric banding from 1993 to 1999. Cardiovascular risk status was again determined in 2010, and the rate of coronary events during long-term (>10 years) follow-up was collected. RESULTS A total of 318 patients (58 men and 260 women) were retrieved. Age at surgery was 38.6 ± 10.4 years. Body mass index was 46.7 ± 7.2 kg/m(2). Follow-up was 12.7 ± 1.5 years. Weight loss was 17.6% ± 15.7% of baseline weight at 12-18 months and 17.1% ± 14.8% at 12.7 years. A significant reduction in blood glucose, total cholesterol, triglycerides, and systolic and diastolic blood pressure was observed at the short-term evaluation and confirmed in the long term. HDL-C was unchanged at 12-18 months and significantly increased at 12.7 years. Five coronary events (1.6%) were recorded during long-term follow-up. The rate of observed events was compared with the rate of events expected according to baseline 10-year probability of myocardial infarction calculated with the Prospective Cardiovascular Munster study (PROCAM) score. Observed rate (1.6%) was slightly lower than the expected rate (2.0%± 4.9%). CONCLUSIONS Stable weight loss and significant improvement of cardiovascular risk profile were observed in morbidly obese patients 10 years after laparoscopic adjustable gastric banding.
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Affiliation(s)
- Luca Busetto
- Department of Medicine, University of Padova, Padova, Italy.
| | | | | | - Gianni Segato
- Department of Surgery, Regional Hospital of Vicenza, Vicenza, Italy
| | - Maurizio De Luca
- Department of Surgery, Regional Hospital of Vicenza, Vicenza, Italy
| | - Franco Favretti
- Department of Surgery, Regional Hospital of Vicenza, Vicenza, Italy
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Fenger RV, Gonzalez-Quintela A, Linneberg A, Husemoen LLN, Thuesen BH, Aadahl M, Vidal C, Skaaby T, Sainz JC, Calvo E. The relationship of serum triglycerides, serum HDL, and obesity to the risk of wheezing in 85,555 adults. Respir Med 2013; 107:816-24. [PMID: 23465506 DOI: 10.1016/j.rmed.2013.02.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 01/25/2013] [Accepted: 02/04/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Asthma has been linked to obesity and the presence of the metabolic syndrome. OBJECTIVE To explore which components of the metabolic syndrome that were associated with wheezing, a main symptom of asthma. Further, to explore whether these associations were different in individuals with and without rhinitis symptoms. METHODS We used data from the Ibermutuamur Cardiovascular Risk Assessment Plan (ICARIA) including 85,555 Spanish workers (median age = 34, range = 16-75 years) with assessments of self reported wheezing and rhinitis symptoms. Fasting blood samples were analysed for serum triglyceride (s-TG), HDL (s-HDL) and glucose; blood pressure, waist circumference (WC) and body mass index (BMI) were measured. RESULTS In mutually adjusted analyses including all components of the metabolic syndrome and possible confounders, elevated WC (or BMI), elevated s-TG and low s-HDL were significantly associated with wheezing. Odds ratio (OR) with confidence interval (CI) were: elevated WC = 1.54 (1.46-1.62), elevated s-TG = 1.24 (1.18-1.30), low s-HDL = 1.17 (1.12-1.22). These associations were stronger in individuals without than in those with rhinitis symptoms, OR's (CI's) were WC = without rhinitis 1.70 (1.57-1.85) vs. with rhinitis 1.47 (1.37-1.58). Elevated s-TG = without rhinitis 1.36 (1.26-1.46) vs. with rhinitis 1.21 (1.13-1.29). Low s-HDL = without rhinitis 1.24 (1.15-1.34) vs. with rhinitis 1.11 (1.04-1.18). CONCLUSIONS High s-TG and low s-HDL were associated with wheezing after adjustment for adiposity. This may substantiate elevated s-TG and lowered s-HDL as markers or inducers of inflammation associated disease. The study supports the notion that these biochemical markers have differential effects on different types of wheezing.
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Affiliation(s)
- R V Fenger
- Research Centre for Prevention and Health, Glostrup University Hospital, Denmark.
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Morbelli S, Marini C, Adami GF, Kudomi N, Camerini G, Iozzo P, Massollo M, Capitanio S, Bodrato S, Verardi MT, Papadia F, Cordera R, Knuuti J, Scopinaro N, Sambuceti G. Tissue specificity in fasting glucose utilization in slightly obese diabetic patients submitted to bariatric surgery. Obesity (Silver Spring) 2013; 21:E175-81. [PMID: 23404920 DOI: 10.1002/oby.20003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 05/05/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The present study was planned to investigate, by means of quantitative FDG-PET, how bariatric surgery (BS) modifies the metabolic pattern of the whole body and different tissues in slightly obese patients with type 2 diabetes mellitus (T2DM). DESIGN AND METHODS Before, 1 and 4 months after BS, 21 consecutive slightly obese T2DM patients underwent blood sampling to estimate plasma levels of glucose, insulin, glycosylated hemoglobin. At the same time points, these patients underwent a dynamic (18) F-FDG PET study of thorax and upper abdomen in fasting state and after washout of T2DM therapy. Gjedde-Patlak analysis was applied to estimate glucose uptake in the whole body and in different tissues (myocardium, skeletal back muscle, adipose tissue, and liver). RESULTS Surgical intervention quickly lowered levels of both insulin and glucose documenting an amelioration of glucose tolerance. Similarly, skeletal muscle and myocardial glucose uptake significantly increased soon after surgery (P < 0.001 and P < 0.01 at 1 month versus baseline, respectively) and remained substantially stable thereafter. By contrast, glucose uptake slightly decreased from its baseline values in the liver (P < 0.01 at 4 months) while no response could be documented over time in the adipose tissue. CONCLUSIONS These findings document that BS-induced modification of glucose homeostasis in slightly obese T2DM patients is mostly due to an increase in muscle glucose consumption. The surgically modified metabolic pattern of these patients might be of interest as a new model to investigate mechanism underlying insulin resistance.
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Affiliation(s)
- Silvia Morbelli
- Nuclear Medicine Unit, Department Internal Medicine, University of Genoa, Genoa, Italy.
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Tsoli M, Chronaiou A, Kehagias I, Kalfarentzos F, Alexandrides TK. Hormone changes and diabetes resolution after biliopancreatic diversion and laparoscopic sleeve gastrectomy: a comparative prospective study. Surg Obes Relat Dis 2013; 9:667-77. [PMID: 23466015 DOI: 10.1016/j.soard.2012.12.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 12/06/2012] [Accepted: 12/09/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss and remission of diabetes type 2 (T2DM), but it is accompanied by nutrient deficiencies. Sleeve gastrectomy (SG) is a relatively new operation that has shown promising results concerning T2DM resolution and weight loss. The objective of this study was to evaluate and compare prospectively the effects of BPD long limb (BPD) and laparoscopic SG on fasting, and glucose-stimulated insulin, glucagon, ghrelin, peptide YY (PYY), and glucagon-like peptide-1 (GLP-1) secretion and also on remission of T2DM, hypertension, and dyslipidemia in morbidly obese patients with T2DM. METHODS Twelve patients (body mass index [BMI] 57.6 ± 9.9 kg/m(2)) underwent BPD and 12 (BMI 43.7 ± 2.1 kg/m(2)) underwent SG. All patients had T2DM and underwent an oral glucose tolerance test (OGTT) before and 1, 3, and 12 months after surgery. RESULTS BMI decreased more after BPD, but percent excess weight loss (%EWL) was similar in both groups (P = .8) and T2DM resolved in all patients at 12 months. Insulin sensitivity improved more after BPD than after SG (P = .003). Blood pressure, total and LDL cholesterol decreased only after BPD (P<.001). Triglycerides decreased after either operation, but HDL increased only after SG (P<.001). Fasting ghrelin did not change after BPD (P = .2), but decreased markedly after SG (P<.001). GLP-1 and PYY responses during OGTT were dramatically enhanced after either procedure (P = .001). CONCLUSIONS SG was comparable to BPD in T2DM resolution but inferior in improving dyslipidemia and blood pressure. SG and BPD enhanced markedly PYY and GLP-1 responses but only SG suppressed ghrelin levels.
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Affiliation(s)
- Marina Tsoli
- Department of Internal Medicine, Division of Endocrinology, School of Medicine, University of Patras, Greece
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Guénard F, Tchernof A, Deshaies Y, Cianflone K, Kral JG, Marceau P, Vohl MC. Methylation and expression of immune and inflammatory genes in the offspring of bariatric bypass surgery patients. J Obes 2013; 2013:492170. [PMID: 23840945 PMCID: PMC3693160 DOI: 10.1155/2013/492170] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/17/2013] [Accepted: 05/22/2013] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Maternal obesity, excess weight gain and overnutrition during pregnancy increase risks of obesity, type 2 diabetes mellitus, and cardiovascular disease in the offspring. Maternal biliopancreatic diversion is an effective treatment for severe obesity and is beneficial for offspring born after maternal surgery (AMS). These offspring exhibit lower severe obesity prevalence and improved cardiometabolic risk factors including inflammatory marker compared to siblings born before maternal surgery (BMS). OBJECTIVE To assess relationships between maternal bariatric surgery and the methylation/expression of genes involved in the immune and inflammatory pathways. METHODS A differential gene methylation analysis was conducted in a sibling cohort of 25 BMS and 25 AMS offspring from 20 mothers. Following differential gene expression analysis (23 BMS and 23 AMS), pathway analysis was conducted. Correlations between gene methylation/expression and circulating inflammatory markers were computed. RESULTS Five immune and inflammatory pathways with significant overrepresentation of both differential gene methylation and expression were identified. In the IL-8 pathway, gene methylation correlated with both gene expression and plasma C-reactive protein levels. CONCLUSION These results suggest that improvements in cardiometabolic risk markers in AMS compared to BMS offspring may be mediated through differential methylation of genes involved in immune and inflammatory pathways.
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Affiliation(s)
- Frédéric Guénard
- Department of Food Science and Nutrition, Institute of Nutrition and Functional Foods (INAF), Laval University, Québec, QC, Canada G1V 0A6
- Endocrinology and Nephrology, CHU de Québec Research Center, Québec, QC, Canada G1V 4G2
| | - André Tchernof
- Endocrinology and Nephrology, CHU de Québec Research Center, Québec, QC, Canada G1V 4G2
- Québec Heart and Lung Institute, Québec, QC, Canada G1V 4G5
| | - Yves Deshaies
- Québec Heart and Lung Institute, Québec, QC, Canada G1V 4G5
- Department of Medicine, Laval University, Québec, QC, Canada G1V 0A6
| | - Katherine Cianflone
- Québec Heart and Lung Institute, Québec, QC, Canada G1V 4G5
- Department of Medicine, Laval University, Québec, QC, Canada G1V 0A6
| | - John G. Kral
- Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Picard Marceau
- Québec Heart and Lung Institute, Québec, QC, Canada G1V 4G5
- Department of Surgery, Laval University, Québec, QC, Canada G1V 0A6
| | - Marie-Claude Vohl
- Department of Food Science and Nutrition, Institute of Nutrition and Functional Foods (INAF), Laval University, Québec, QC, Canada G1V 0A6
- Endocrinology and Nephrology, CHU de Québec Research Center, Québec, QC, Canada G1V 4G2
- *Marie-Claude Vohl:
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Yin DP, Boyd KL, Williams PE, Abumrad NN, Wasserman DH. Mouse Models of Bariatric Surgery. CURRENT PROTOCOLS IN MOUSE BIOLOGY 2012; 2012:mo120087. [PMID: 25364628 PMCID: PMC4214370 DOI: 10.1002/9780470942390.mo120087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Morbid obesity is linked to increased incidences of glucose intolerance, Type 2 diabetes mellitus, cardiovascular diseases, various forms of liver disease, and specific forms of cancer. Treatment of obesity by lifestyle modifications (i.e. changes in diet and exercise) and drug therapy is generally ineffective. Bariatric surgery is currently the most effective means of treating obesity and related disorders. We as well as others have developed surgical procedures for application to genetic mouse models that mimic an array of human bariatric surgical procedures used in the treatment of obesity. The application of bariatric surgery to genetic mouse models will broaden our understanding of the role of the gut in metabolic disease. Models that have been developed include gastric banding, sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) with a complete exclusion of the stomach, duodenal-jejunal bypass (DJB) and biliopancreatic diversion (BPD). The detailed methods of these procedures are provided.
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Affiliation(s)
- Deng Ping Yin
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Mouse Metabolic Phenotyping Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Kelli L. Boyd
- Department of Pathology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Mouse Metabolic Phenotyping Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Phillip E. Williams
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Diabetes Research Training Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Naji N. Abumrad
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Diabetes Research Training Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - David H. Wasserman
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Mouse Metabolic Phenotyping Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Diabetes Research Training Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Effect of gastrointestinal surgical manipulation on metabolic syndrome: a focus on metabolic surgery. Gastroenterol Res Pract 2012; 2012:670418. [PMID: 23133447 PMCID: PMC3485504 DOI: 10.1155/2012/670418] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 09/06/2012] [Indexed: 12/20/2022] Open
Abstract
Metabolic syndrome is strictly associated with morbid obesity and leads to an increased risk of cardiovascular diseases and related mortality. Bariatric surgery is considered an effective option for the management of these patients. We searched MEDLINE, Current Contents, and the Cochrane Library for papers published on bariatric surgery outcomes in English from 1 January 1990 to 20 July 2012. We reported the effect of gastrointestinal manipulation on metabolic syndrome after bariatric surgery. Bariatric surgery determines an important resolution rate of major obesity-related comorbidities. Roux-en-Y gastric bypass and biliopancreatic diversion appear to be more effective than adjustable gastric banding in terms of weight loss and comorbidities resolution. However, the results obtained in terms of weight loss and resolution of comorbidities after a “new bariatric procedure” (sleeve gastrectomy) encouraged and stimulated the diffusion of this operation.
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Heneghan HM, Nissen S, Schauer PR. Gastrointestinal Surgery for Obesity and Diabetes: Weight Loss and Control of Hyperglycemia. Curr Atheroscler Rep 2012; 14:579-87. [DOI: 10.1007/s11883-012-0285-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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The Effect of Gastrointestinal Surgery on Insulin Resistance and Insulin Secretion. Curr Atheroscler Rep 2012; 14:624-30. [DOI: 10.1007/s11883-012-0284-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Castagneto-Gissey L, Mingrone G. Insulin sensitivity and secretion modifications after bariatric surgery. J Endocrinol Invest 2012; 35:692-8. [PMID: 22732257 DOI: 10.3275/8470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Type 2 diabetes mellitus is increasing over time as result of the obesity epidemics. In fact, the prevalence of Type 2 diabetes across Europe in 2010 was estimated to be 8.2% of the population and its projection for 2030 sees figures of 10.1%. This increase in the number of diabetic individuals has also dramatically raised the health expense, with spending on diabetes in Europe in 2010 accounting for 10% of the total healthcare cost. A meta-analysis of the literature evidenced that the clinical and laboratory manifestations of Type 2 diabetes are resolved in 78.1%, and are improved in 86.6% of obese patients (body mass index >35 kg/m²) after bariatric surgery. However, a gradation of effects of different surgical techniques in improving glucose control does exist, with the largest and durable effects observed in prevalently malabsorptive procedures. The outcome of bariatric surgery on insulin sensitivity and secretion is different in relation to the type of operation performed. In fact, while Roux-en-Y Gastric Bypass enhances insulin secretion after a meal thus improving glucose metabolism, Bilio-Pancreatic Diversion acts through the amelioration of insulin sensitivity allowing a subsequent reduction of insulin hypersecretion, which is a typical feature of the insulin resistance state. Gastric banding action is mediated uniquely through the weight loss, and the effect of sleeve gastrectomy is still to be elucidated. Incretin secretion is dramatically increased under nutrient stimulation after gastric bypass leading, probably, to an overstimulation of pancreatic β-cells resulting in the increase of insulin secretion.
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Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, Thomas S, Abood B, Nissen SE, Bhatt DL. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012; 366:1567-76. [PMID: 22449319 PMCID: PMC3372918 DOI: 10.1056/nejmoa1200225] [Citation(s) in RCA: 1532] [Impact Index Per Article: 127.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Observational studies have shown improvement in patients with type 2 diabetes mellitus after bariatric surgery. METHODS In this randomized, nonblinded, single-center trial, we evaluated the efficacy of intensive medical therapy alone versus medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy in 150 obese patients with uncontrolled type 2 diabetes. The mean (±SD) age of the patients was 49±8 years, and 66% were women. The average glycated hemoglobin level was 9.2±1.5%. The primary end point was the proportion of patients with a glycated hemoglobin level of 6.0% or less 12 months after treatment. RESULTS Of the 150 patients, 93% completed 12 months of follow-up. The proportion of patients with the primary end point was 12% (5 of 41 patients) in the medical-therapy group versus 42% (21 of 50 patients) in the gastric-bypass group (P=0.002) and 37% (18 of 49 patients) in the sleeve-gastrectomy group (P=0.008). Glycemic control improved in all three groups, with a mean glycated hemoglobin level of 7.5±1.8% in the medical-therapy group, 6.4±0.9% in the gastric-bypass group (P<0.001), and 6.6±1.0% in the sleeve-gastrectomy group (P=0.003). Weight loss was greater in the gastric-bypass group and sleeve-gastrectomy group (-29.4±9.0 kg and -25.1±8.5 kg, respectively) than in the medical-therapy group (-5.4±8.0 kg) (P<0.001 for both comparisons). The use of drugs to lower glucose, lipid, and blood-pressure levels decreased significantly after both surgical procedures but increased in patients receiving medical therapy only. The index for homeostasis model assessment of insulin resistance (HOMA-IR) improved significantly after bariatric surgery. Four patients underwent reoperation. There were no deaths or life-threatening complications. CONCLUSIONS In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. Further study will be necessary to assess the durability of these results. (Funded by Ethicon Endo-Surgery and others; ClinicalTrials.gov number, NCT00432809.).
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Affiliation(s)
- Philip R Schauer
- Bariatric and Metabolic Institute, Cleveland Clinic M61, 9500 Euclid Ave., Cleveland, OH 44195, USA.
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Sala PC, Torrinhas RS, Heymsfield SB, Waitzberg DL. Type 2 diabetes mellitus: a possible surgically reversible intestinal dysfunction. Obes Surg 2012; 22:167-76. [PMID: 22094369 DOI: 10.1007/s11695-011-0563-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Type 2 diabetes mellitus (T2DM) is a global public health problem often associated with obesity. Bariatric surgery is effective for treating serious obesity, and techniques involving intestinal bypass have metabolic benefits, such as complete and early remission of T2DM. We present a literature review of the possible mechanisms of early normalization of glycemic homeostasis after bariatric surgery, including intestinal gluconeogenesis, increased antidiabetogenic signals from L cells located in the distal small intestine, and impaired secretion of diabetogenic signals in the upper part of the small intestine. Adding to these potential mechanisms, unknown factors that regulate insulin sensitivity may be involved and altered by bariatric surgery. This review discusses the various hypotheses about the mechanisms of glycemic control after bariatric surgery involving intestinal bypass. Further research is essential to better understand these mechanisms and to identify potential new mechanisms that might help in developing less invasive and safer alternatives for the treatment of T2DM and reveal novel pharmaceutical targets for glycemic control.
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Affiliation(s)
- Priscila C Sala
- Department of Gastroenterology, Digestive Surgery Discipline, LIM 35, University of São Paulo, Medical School, Av Dr Arnaldo, 455 Cerqueira César, CEP 01246-930 São Paulo, Brazil.
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Scopinaro N, Adami GF, Papadia FS, Camerini G, Carlini F, Briatore L, D'Alessandro G, Parodi C, Weiss A, Andraghetti G, Catalano M, Cordera R. The effects of biliopancreatic diversion on type 2 diabetes mellitus in patients with mild obesity (BMI 30-35 kg/m2) and simple overweight (BMI 25-30 kg/m2): a prospective controlled study. Obes Surg 2012; 21:880-8. [PMID: 21541815 DOI: 10.1007/s11695-011-0407-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Beneficial effects of BPD on T2DM in BMI >35 kg/m(2) patients are far better than those in patients with BMI 25-35. This study was aimed at investigating if a similar difference exists between patients with mild obesity (OB, BMI 30-35) or simple overweight (OW, BMI 25-30). METHODS Fifteen OB (six M) and 15 OW (13 M), diabetic for ≥ 3 years, with HbA1c ≥ 7.5% despite medical therapy, underwent BPD. OB/OW: age 55.1 ± 8.0/57.8 ± 6.7 years, BMI 33.1 ± 1.5/28.0 ± 1.3 kg/m(2), diabetes duration 11.6 ± 8.0/11.1 ± 6.1 years, insulin therapy 4/8 p. FSG and HbA1c were determined preoperatively and up to 2 years. Insulin resistance and beta-cell function were explored by means of HOMA-IR and IVGTT (AIR). Thirty-eight diabetic patients on medical therapy served as controls. RESULTS Mean BMI stabilized around 27 since the 4th month in OB, and 24 since 1st month in OW. FSG in OB/OW preop, 1, 12, 24 months: 234 ± 76/206 ± 62 mg/dL, 154 ± 49/176 ± 75, 131 ± 32/167 ± 48, 134 ± 41/154 ± 41 (cross-sectional n.s. at all times); HbA1c: 9.5 ± 1.6/9.1 ± 1.3, 7.3 ± 1.1/7.3 ± 1.2, 5.9 ± 0.6/7.1 ± 1.1 (p < 0.01), 5.9 ± 0.9/6.9 ± 1.1 (p < 0.01). HOMA-IR, preoperatively 10.7 ± 5.8/7.5 ± 5.4, went below 3.0 at 1 month and remained such until 2 years in both groups. AIR, preoperatively 1.11 ± 3.17/1.27 ± 2.68 μIU/mL, in OB significantly increased at 4 months to 7.63 ± 5.79, maintained up to 2 years with 6.95 ± 3.19, whereas in OW, statistical significance was reached only at 2 years with 5.02 ± 4.87. CONCLUSIONS Significantly different BPD effect, thus biological severity of T2DM, also exists between mildly obese and simply overweight patients. The rise of AIR allows hoping that an increase of beta-cell mass may occur in the long run.
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Affiliation(s)
- Nicola Scopinaro
- Department of Surgery, University of Genoa Medical School, Genoa, Italy.
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Diabetic and bariatric surgery: A review of the recent trends. Surg Endosc 2011; 26:893-903. [DOI: 10.1007/s00464-011-1976-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 09/23/2011] [Indexed: 12/25/2022]
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Abstract
Published data show that bariatric surgery not only leads to significant and sustained weight loss but also resolves or improves multiple comorbidities associated with morbid obesity. Evidence suggests that the earlier the intervention the better the resolution of comorbidities. Patients with metabolic syndrome and comorbidities associated with morbid obesity should be promptly referred for consideration for bariatric surgery earlier in the disease process.
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Affiliation(s)
- Ashutosh Kaul
- Department of Surgery, Westchester Medical Center, 100 Woods Road PMB 583, Valhalla, NY 10595, USA.
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Bariatrics, metabolic dysfunction and the surgeon. Indian J Surg 2011; 72:283-4. [PMID: 21938188 DOI: 10.1007/s12262-010-0151-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Abstract
Conventional bariatric operations, including Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding, and biliopancreatic diversion (BPD) appear to be a safe and effective treatment for many severely obese patients with type 2 diabetes mellitus (T2DM). These operations improve glucose homeostasis through a variety of mechanisms, however, not only due to reduced food intake and body weight. Research to elucidate the weight-independent antidiabetic mechanisms of gastrointestinal (GI) surgery and to clarify the molecular mechanisms responsible for the benefits of GI surgery on glucose homeostasis is a compelling research objective. We review the existing knowledge regarding the clinical outcomes and of the mechanisms of GI surgery to treat T2DM.
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Affiliation(s)
- Soo Min Ahn
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York 10065, USA
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Smith BR, Schauer P, Nguyen NT. Surgical approaches to the treatment of obesity: bariatric surgery. Med Clin North Am 2011; 95:1009-30. [PMID: 21855705 DOI: 10.1016/j.mcna.2011.06.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
As the obesity epidemic continues to grow in the Unites States, so does the search for the ideal nonsurgical or surgical solution. Bariatric surgery continues to be the most sustainable form of weight loss available to morbidly obese patients. In addition, bariatric surgery has established an acceptable safety profile with respect to morbidity and mortality. With the number of elective bariatric cases growing in recent years, it is unsurprising that results have improved and better data are emerging regarding improvement of obesity-related comorbid conditions. Additionally, ample evidence suggests that bariatric surgery may increase longevity, particularly through reducing cardiovascular deaths. Although the specific mechanisms involved in the remission of these medical conditions remain to be fully elucidated, it has become clear that bariatric surgery has established a significant and firm role in the treatment of medical comorbidities that result directly from obesity. However, until commercial insurance carriers provide improved coverage for bariatric surgery, patient access to these treatments will remain limited.
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Affiliation(s)
- Brian R Smith
- University of California, Irvine Medical Center, Orange, CA, USA
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Assessment of different bariatric surgeries in the treatment of obesity and insulin resistance in mice. Ann Surg 2011; 254:73-82. [PMID: 21522012 DOI: 10.1097/sla.0b013e3182197035] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the effects of different bariatric surgical procedures on the treatment of obesity and insulin resistance in high fat diet-induced obese (DIO) mice. BACKGROUND Bariatric surgery is currently considered the most effective treatment for morbid obesity and its comorbidities; however, a systematic study of their mechanisms is still lacking. METHODS We developed bariatric surgery models, including gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), modified RYGB (mRYGB) and biliopancreatic diversion (BPD), in DIO mice. Body weight, body fat and lean mass, liver steatosis, glucose tolerance and pancreatic beta cell function were examined. RESULTS All bariatric surgeries resulted in significant weight loss, reduced body fat and improved glucose tolerance in the short term (4 weeks), compared with mice with sham surgery. Of the bariatric surgery models, sleeve gastrectomy and mRYGB had higher success rates and lower mortalities and represent reliable restrictive and gastrointestinal (GI) bypass mouse bariatric surgery models, respectively. In the long term, the GI bypass procedure produced more profound weight loss, significant improvement of glucose tolerance and liver steatosis than the restrictive procedure. DIO mice had increased insulin promoter activity, suggesting overactivation of pancreatic beta cells, which was regulated by the mRYGB procedure. Compared with the restrictive procedure, the GI bypass procedure showed more severe symptoms of malnutrition following bariatric surgery. DISCUSSIONS Both restrictive and GI bypass procedures provide positive effects on weight loss, fat composition, liver steatosis and glucose tolerance; however, in the long term, the GI bypass shows better results than restrictive procedures.
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86
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DePaula AL, Stival AR, Halpern A, Vencio S. Surgical treatment of morbid obesity: mid-term outcomes of the laparoscopic ileal interposition associated to a sleeve gastrectomy in 120 patients. Obes Surg 2011; 21:668-75. [PMID: 20652440 DOI: 10.1007/s11695-010-0232-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The aim of this study was to evaluate the mid-term outcomes of the laparoscopic ileal interposition associated to a sleeve gastrectomy (LII-SG) for the treatment of morbid obesity. The procedure was performed in 120 patients: 71 women and 49 men with mean age of 41.4 years. Mean body mass index (BMI) was 43.4 ± 4.2 kg/m². Patients had to meet requirements of the 1991 NIH conference criteria for bariatric operations. Associated comorbidities were observed in all patients, including dyslipidemia in 51.7%, hypertension in 35.8%, type 2 diabetes in 15.8%, degenerative joint disease in 55%, gastroesophageal reflux disease in 36.7%, sleep apnea in 10%, and cardiovascular problems in 5.8%. Mean follow-up was 38.4 ± 10.2 months, range 25.2-61.1. There was no conversion to open surgery nor operative mortality. Early major complications were diagnosed in five patients (4.2%). Postoperatively, 118 patients were evaluated. Late major complications were observed in seven patients (5.9%). Reoperations were performed in six (5.1%). Mean postoperative BMI was 25.7 ± 3.17 kg/m², and 86.4% were no longer obese. Mean %EWL was 84.5 ± 19.5%. Hypertension was resolved in 88.4% of the patients, dyslipidemia in 82.3%, and T2DM in 84.2%. The LII-SG provided an adequate weight loss and resolution of associated diseases during mid-term outcomes evaluation. There was an acceptable morbidity with no operative mortality. It seems that chronic ileal brake activation determined sustained reduced food intake and increased satiety over time. LII-SG could be regularly used as a surgical alternative for the treatment of morbid obesity.
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Affiliation(s)
- Aureo L DePaula
- Department of Surgery, Hospital de Especialidades, Goiania, Brazil.
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Yin J, Mao ZQ, Zhou XJ, Xu L, Zhu Z, Chen X. Treatment of type 2 diabetes mellitus by laparoscopic gastric bypass: an analysis of 26 cases. Shijie Huaren Xiaohua Zazhi 2011; 19:2391-2394. [DOI: 10.11569/wcjd.v19.i22.2391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To summarize the initial experience with laparoscopic Roux-en-Y gastric bypass (LRYGB) in the management of patients with type 2 diabetes mellitus (T2DM).
METHODS: The clinical data for 26 T2DM patients (BMI ≥24 kg/m2, HbAlc ≥7%, peptide C ≥1 μg/L) who received laparoscopic gastric bypass from May 2010 to November 2010 were retrospective1y analyzed. The changes in FBG, HbAlc, insulin and peptide C levels and in doses of hypoglycemic agents at different postoperative time points (1, 3 and 6 mo) were analyzed.
RESULTS: The operation was successful in all cases. Postoperatively, one case developed anastomotic bleeding and 2 cases developed gastroparesis, but they were all cured after conservative medical management. All cases have been followed up and the total effective rate of the operation was 96.3%. Eleven cases were free of dependence on hypoglycemic agents from weeks 3 to 8 after LRYGB, and the 3- and 6-month cure rates were 36.7% and 50%, respectively.
CONCLUSION: LRYGP is safe, feasible and effective in the management of T2DM in the short term, and long-term efficacy still need further clinical follow-up.
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de la Cruz-Muñoz N, Messiah SE, Arheart KL, Lopez-Mitnik G, Lipshultz SE, Livingstone A. Bariatric surgery significantly decreases the prevalence of type 2 diabetes mellitus and pre-diabetes among morbidly obese multiethnic adults: long-term results. J Am Coll Surg 2011; 212:505-11; discussion 512-3. [PMID: 21463779 DOI: 10.1016/j.jamcollsurg.2010.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 12/14/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Type 2 diabetes (T2DM) and obesity are codependent epidemics that disproportionately affect ethnic minorities. Recent studies have shown that in non-Hispanic whites, bariatric surgical procedures successfully reverse or improve abnormal glucose metabolism, yet little is known about the results of bariatric surgery in Hispanic and other ethnic minority adults with T2DM. STUDY DESIGN A retrospective analysis of 1,603 adults (77% female, 66% Hispanic, mean age at surgery 45.1 years [SD 11.6 years]) who underwent bariatric surgery from 2002 to 2010 was conducted. A total of 377 subjects had diagnosed T2DM, 107 had fasting plasma glucose (FPG) ≥126 mg/dL but were not on T2DM medication, 276 were pre-diabetic (FPG = 100 to 125 mg/dL), and 843 had normal FPG. Pre-surgery and 6, 12, 24, and 36 months post-surgery comparative-means analyses of weight, body mass index, estimated weight loss, hemoglobin A1c, and FPG were conducted via repeated-measures analysis. RESULTS By 1 year and through 3 years post-surgery, all groups had normal FPG. Patients with undiagnosed diabetes had a 43% FPG decrease followed by diagnosed diabetics (33%). Patients with diagnosed diabetes showed a slightly greater loss in hemoglobin A1c (2.30%) versus undiagnosed diabetics (2.13%). Patients with pre-diabetes saw the most dramatic loss in weight (47.00 kg), followed by patients with undiagnosed diabetes (46.62 kg), normal FPG (43.14 kg), and patients with diagnosed diabetes (41.39 kg) (p < 0.0001 for all up to 24 months). CONCLUSIONS Bariatric surgery results in significant long-term weight loss and improvement in FPG levels among ethnically diverse adults. Bariatric surgery has the potential to be an effective treatment option for weight loss and chronic disease risk improvements in this demographic.
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Kashyap SR, Gatmaitan P, Brethauer S, Schauer P. Bariatric surgery for type 2 diabetes: weighing the impact for obese patients. Cleve Clin J Med 2011; 77:468-76. [PMID: 20601620 DOI: 10.3949/ccjm.77a.09135] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Obesity is a potent risk factor for the development and progression of type 2 diabetes, and weight loss is a key component of diabetes management. Bariatric surgery results in significant weight loss and remission of diabetes in most patients. After surgery, glycemic control is restored by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion.
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Affiliation(s)
- Sangeeta R Kashyap
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH 44195, USA.
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90
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Tur J, Alòs M, Iglesias L, Luque L, Colom A, Escudero A, Martínez D, Pagán A, Ugarriza E, Frontera M, Nicola G, Palomero A, Tofé S, Urgeles JR, Barceló MA, Couce M, De La Peña M, Fiol M, Cortés B, Terés E, Tumbarello Á, Álvarez C, Salinas R, Pereg V, González X, Burguera B. TRAMOMTANA (Tratamiento Multidisciplinar de la Obesidad Mórbida: Medicamentos, Terapia de comportamiento, Apoyo Nutricional y Actividad física). De la pregunta a la realidad de un ensayo clínico investigador iniciado (II). ACTA ACUST UNITED AC 2011; 58:299-307. [DOI: 10.1016/j.endonu.2011.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 04/12/2011] [Accepted: 04/14/2011] [Indexed: 11/24/2022]
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Crea N, Pata G, Di Betta E, Greco F, Casella C, Vilardi A, Mittempergher F. Long-term results of biliopancreatic diversion with or without gastric preservation for morbid obesity. Obes Surg 2011; 21:139-45. [PMID: 21116732 DOI: 10.1007/s11695-010-0333-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We aimed at comparing our long-term results after biliopancreatic diversion (BPD) with or without gastric preservation for morbid obesity. Between 1999 and 2009, we performed 540 BPD: 287 patients (group A) underwent BPD with distal gastric resection (BPD-AHS) and 253 (group B) underwent BPD associated with transitory vertical gastroplasty (TGR) with duodenal switch (DS). The results have been analyzed in terms of weight loss, improvement of comorbidities, and quality of life (Bariatric Analysis and Reporting Outcome System). The mean follow-up was 7.4 ± 2.9 years. One year after surgery, mean initial excess weight loss percentage was 69% for patients in group A (n = 287) and 65% for group B (n = 253); after 2-5 years, it was 74% for patients who underwent BPD-AHS (n = 130) and 75% for patients who underwent BPD-TGR-DS (n = 116); it was 71% and 74% for patients in group A (n = 157) and B (n = 137), respectively, followed up for >5 years (P = 0.27). Among the diabetic patients in both groups (191 patients), 64% discontinued the medication with insulin (P = 0.25), and 98% had stopped oral drugs within 1 year from surgery (P = 0.29). We did not observe deficiencies of vitamins and proteins. The overall incidence of incisional hernias was 38% (P = 0.35). We recorded 13 anastomotic ulcers (2.4%; P = 0.28). BPD represents, in spite of the side effects, an effective technique for treatment of morbid obesity and its associated diseases. Moreover, our results showed that patients who underwent BPD-TGR-DS had slightly better results in terms of postoperative metabolic complications and improvement in quality of life.
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Affiliation(s)
- Nicola Crea
- 1st Division of General Surgery, Department of Medical & Surgical Sciences, University of Brescia, Brescia, Italy.
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Blüher S, Till H, Kiess W. Bariatrische Chirurgie bei extremer Adipositas im Kindes- und Jugendalter. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2011; 54:577-83. [DOI: 10.1007/s00103-011-1268-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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93
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Lee HC, Kim MK, Kwon HS, Kim E, Song KH. Early changes in incretin secretion after laparoscopic duodenal-jejunal bypass surgery in type 2 diabetic patients. Obes Surg 2011; 20:1530-5. [PMID: 20803098 DOI: 10.1007/s11695-010-0248-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND A stomach-preserving duodenal-jejunal bypass (DJB) has been used for the treatment of type 2 diabetes mellitus (DM) since Rubino et al. first reported a prospective trial. However, there has been no report on changes in incretin secretion after DJB. We aimed to investigate whether DJB changes incretin secretion in nonmorbidly obese type 2 diabetic patients. METHODS The inclusion criteria in this prospective study were: patient age of 20-65 years, body mass index of <30 kg/m(2), a history of type 2 DM for ≤10 years, and fasting C-peptide ≥0.3 nmol/l. Six patients with type 2 DM without morbid obesity underwent DJB. Fasting plasma glucose and glycated hemoglobin (HbA1c) were measured. An oral glucose tolerance test (OGTT) was performed with measurement of glucagon-like peptide 1 (GLP-1), glucose-dependent insulinotropic peptide (GIP), insulin, C-peptide, and glucagon. The study subjects were followed up for 6 months. RESULTS The body weight of patients declined after surgery. The area under the curve (AUC) of glucose, peak glucose levels during OGTT, and HbA1c also declined until 3 months postoperatively. The AUC of C-peptide and insulin tended to increase postoperatively. The AUC of glucagon had a significant increase at 6 months postoperatively. The AUC of active GLP-1 increased at 1 month and at 6 months postoperatively. There was no change in the AUC of total GIP. CONCLUSION Our data suggest that DJB increases GLP-1 secretion in nonmorbidly obese type 2 diabetic patients. However, long-term data are needed to confirm this finding.
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Affiliation(s)
- Hong Chan Lee
- Department of Surgery, The Catholic University of Korea, Seoul, Korea
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Abstract
BACKGROUND
Multiple genes that are associated with the risk of developing diabetes or the risk of diabetes complications have been identified by candidate gene analysis and genomewide scanning. These molecular markers, together with clinical data and findings from proteomics, metabolomics, pharmacogenetics, and other methods, lead to a consideration of the extent to which personalized approaches can be applied to the treatment of diabetes mellitus.
CONTENT
Known genes that cause monogenic subtypes of diabetes are reviewed, and several examples are discussed in which the genotype of an individual with diabetes can direct considerations of preferred choices for glycemic therapy. The extent of characterization of polygenic determinants of type 1 and type 2 diabetes is summarized, and the potential for using this information in personalized management of glycemia and complications in diabetes is discussed. The application and current limitations of proteomic and metabolomic methods in elucidating diabetes heterogeneity is reviewed.
SUMMARY
There is established heterogeneity in the determinants of diabetes and the risk of diabetes complications. Understanding the basis of this heterogeneity provides an opportunity for personalizing prevention and treatment strategies according to individual patient clinical and molecular characteristics. There is evidence-based support for benefits from a personalized approach to diabetes care in patients with certain monogenic forms of diabetes. It is anticipated that strategies for individualized treatment decisions in the more common forms of diabetes will emerge with expanding knowledge of polygenic factors and other molecular determinants of disease.
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Affiliation(s)
- Noemi Malandrino
- Division of Endocrinology, Department of Medicine, Alpert Medical School of Brown University, Providence, RI; Hallett Center for Diabetes and Endocrinology, Rhode Island Hospital, Providence, RI
| | - Robert J Smith
- Division of Endocrinology, Department of Medicine, Alpert Medical School of Brown University, Providence, RI; Hallett Center for Diabetes and Endocrinology, Rhode Island Hospital, Providence, RI
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Surgery needs better support from EU. Surg Endosc 2011; 25:339-42. [PMID: 21234605 DOI: 10.1007/s00464-010-1562-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Frenken M, Cho EY, Karcz WK, Grueneberger J, Kuesters S. Improvement of type 2 diabetes mellitus in obese and non-obese patients after the duodenal switch operation. J Obes 2011; 2011:860169. [PMID: 21461399 PMCID: PMC3065014 DOI: 10.1155/2011/860169] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 01/13/2011] [Indexed: 02/05/2023] Open
Abstract
Introduction. Type 2 diabetes mellitus (T2DM) is one of the most important obesity-related comorbidities. This study was undertaken to characterise the effect of the biliopancreatic diversion with duodenal switch (BPD-DS) in morbidly obese and nonmorbidly obese diabetic patients. Methods. Outcome of 74 obese diabetic patients after BPD-DS and 16 non-obese diabetic patients after BPD or gastric bypass surgery was evaluated. Insulin usage, HbA(1c)-levels, and index of HOMA-IR (homeostasis model assessment of insulin resistence) were measured. Results. A substantial fraction of patients is free of insulin and shows an improved insulin sensitivity early after the operation, another fraction gets free of insulin in a 12-month period after the operation and a small fraction of long-term insulin users will not get free of insulin but nevertheless shows an improved metabolic status (less insulin needed, normal HbA(1c)-levels). Conclusion. BPD-DS leads to an improvement of T2DM in obese and non-obese patients. Nevertheless, more data is needed to clarify indications and mechanisms of action and to adjust our operation techniques to the needs of non-obese diabetic patients.
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Affiliation(s)
- M. Frenken
- Department of Surgery, St. Josef Hospital Monheim, 40789 Monheim am Rhein, Germany
| | - E. Y. Cho
- Department of Surgery, St. Josef Hospital Monheim, 40789 Monheim am Rhein, Germany
| | - W. K. Karcz
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - J. Grueneberger
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - S. Kuesters
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
- *S. Kuesters:
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Cho EY, Kemmet O, Frenken M. Biliopancreatic diversion with duodenal switch in patients with type 2 diabetes mellitus: is the chance of complete remission dependent on therapy and duration of insulin treatment? Obes Facts 2011; 4 Suppl 1:18-23. [PMID: 22027285 PMCID: PMC6444525 DOI: 10.1159/000327037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Rapid resolution of type 2 diabetes mellitus (T2DM) is a common feature after intestinal bypass surgery bypassing the duodenum and parts of the jejunum. However, the parameters determining the individual chance of remission are imprecisely defined. METHODS Biliopancreatic diversion with duodenal switch and sleeve gastrectomy (BPD-DS) was performed in n = 86 patients with T2DM (mean age 50 years, range 26-68, 51 females; BMI 47 kg/m(2), range 26-71). The patients were retrospectively divided into 4 groups according to the treatment modality and the duration of insulin treatment preoperatively: n = 18 patients were treated with oral antidiabetic drugs only (group 1); n = 32, n = 24, and n = 12 patients were treated with insulin for less than 5 years, for 5-10 years, and for more than 10 years (groups 2, 3, and 4), respectively. RESULTS At discharge from hospital, all patients of groups 1 and 2 were free of insulin usage, 30% and 75% of the patients of groups 3 and 4 used up to 48 units of insulin per day (mean 24, n = 16). After 1 year, only 4 patients of group 4 permanently required small amounts of insulin (mean 17 units per day) to keep blood glucose below 200 mg/dl. These 4 patients had been using insulin preoperatively for 13, 15, 22, and 25 years. In 3 of these 4 patients, fasting C-peptide was measured and found to be low (<1.2 ng/ml). The rate of complete remission of diabetes for the whole study population was 91%. CONCLUSION BPD-DS reliably causes rapid and complete remission of T2DM in all patients on oral antidiabetic drugs and in patients with insulin treatment for less than 5 years. In patients with insulin treatment longer than 5 or 10 years, complete remission rates decline to 88 and 66%, respectively. A low C-peptide preoperatively might be a specific adverse prognostic parameter for the chance of diabetes remission.
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Affiliation(s)
| | | | - Michael Frenken
- *Chirurgische Abteilung, St. Josef Krankenhaus Monheim, Alte Schulstrase 21–23, 40789 Monheim, Germany,
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Hussain M, Pomp A. Biliopancreatic Diversion with Duodenal Switch in the Treatment of Diabetes: An Argument that a Chance to Cut is a Chance to Cure. Can J Diabetes 2011. [DOI: 10.1016/s1499-2671(11)52007-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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99
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Sharma AM, Padwal R, Karmali S, W. Birch D. Is it Time to Seriously Target Obesity to Prevent and Control Diabetes? Can J Diabetes 2011. [DOI: 10.1016/s1499-2671(11)52010-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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100
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Frenken M, Cho EY. Metabolic intestinal bypass surgery for type 2 diabetes in patients with a BMI <35 kg/m2: comparative analysis of 16 patients undergoing either BPD, BPD-DS, or RYGB. Obes Facts 2011; 4 Suppl 1:13-7. [PMID: 22027284 PMCID: PMC6444621 DOI: 10.1159/000327038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Metabolic surgery for type 2 diabetes mellitus in patients with low body mass index (BMI) is a novel concept. Early studies show the surgery to be safe and effective but are inconclusive regarding the most effective procedure. METHODS Metabolic intestinal bypass surgery was performed in n = 16 patients with type 2 diabetes and a BMI < 35 kg/m(2) (mean age 56 years, range 36-68; 8 females; mean BMI 32 kg /m(2), range 26-34.5). Biliopancreatic diversion with duodenal switch (BPD-DS), biliopancreatic diversion according to Scopinaro (BPD), and Roux-en-Y gastric bypass (RYGB) were performed in 7, 5, and 4 diabetic patients, respectively. Mean preoperative duration of medical antidiabetic therapy was 16 years (range 4-40). Thirteen patients used insulin on average for 6 years (range 1-12), the mean insulin requirement was 92 IU per day (range 30-140). The analysis was accomplished retrospectively from data prospectively collected in our data base. RESULTS At discharge from hospital, only 3 of the 13 patients who used insulin preoperatively required small amounts of insulin (mean 21 IU per day, range 15-30) to keep fasting and postprandial plasma glucose levels below 200 mg/dl. After 1 year, none of the patients used insulin or oral antidiabetic drugs. The HbA1c level decreased for the total patient population from 8.6% (range 5.8-12.1) preoperatively to 6.0% (range 4.3-7.8), 5.7% (range 4.1-7.6), and 5.6% (range 4.1-7.8) after 3, 6, and 12 months, respectively. The HbA1c levels at 1 year were significantly lower after BPD-DS and BPD than after RYGB (5.2%, range 4.1-6.4 versus 6.7%, range 5.8-7.8, p < 0.01, DHbA1c 1.4%, 95% confidence interval 0.5-2.4). CONCLUSION Metabolic intestinal bypass surgery for type 2 diabetes in low BMI patients is effective, with HbA1c levels at 1 year after the operation being significantly lower after BPD-DS or BPD than after RYGB.
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Affiliation(s)
- Michael Frenken
- Department of Surgery, St Josef Krankenhaus Monheim, Germany.
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