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

Gut Microbiota Imbalance Can Be Associated with Non-malabsorptive Small Bowel Shortening Regardless of Blind Loop

INTRODUCTION

Some traditional bariatric surgery procedures may lead to functional gut shortening, which may unsettle the fine-tuned gastrointestinal physiology and affect gut microbiota balance.

PURPOSE

Evaluate the gut microbiota behavior in rat models facing gut shortening due to intestinal bypass.

MATERIALS AND METHODS

Wistar rats (n = 17) were randomly distributed in three groups: (1) sham group (n = 5); (2) blind loop group (n = 6); and (3) resection group (n = 6). Intestinal samples and feces were analyzed to measure bacterial concentrations (small intestinal bacterial overgrowth-SIBO) 12 weeks after the experimental procedures. Bacterial translocation (BT) was investigated in the mesenteric lymph node (MLN), liver, spleen, and lung of the animals. In addition, inflammatory aspects were investigated in their liver and small bowel through histological analysis.

RESULTS

Regardless of blind loop, gut shortening groups recorded similar high level of bacterial concentrations in intestine compartments, greater than that of the sham group (p ≤ 0.05). BT was only observed in the MLN of gut shortening models, with higher percentage in the blind loop group (p ≤ 0.05). The gut and liver histopathological analysis showed similar low-grade chronic inflammation in both gut shortening groups, likely associated with SIBO/BT events.

CONCLUSION

Sustained SIBO/BT was associated with proximal gut shortening in half regardless of blind loop, whereas the GI tract's ability to restore gut microbiota balance after a surgical challenge on the small bowel appears to be linked to the functional remaining gut.

Validating Risk Prediction Models of Diabetes Remission After Sleeve Gastrectomy

INTRODUCTION

Many risk prediction models of diabetes remission after bariatric and metabolic surgery have been proposed. Most models have been created using Roux-en-Y gastric bypass cohorts. However, validation of these models in sleeve gastrectomy (SG) is limited. The objective of our study is to validate the performance of risk prediction models of diabetes remission in obese patients with diabetes who underwent SG.

METHOD

This retrospective cohort study included 128 patients who underwent SG with at least 1 year follow-up from Dec 2011 to Sep 2016 as the validation cohort. A literature review revealed total 11 models with 2 categories (scoring system and logistic regression), which were validated by our study dataset. Discrimination was evaluated by area under the receiver operating characteristic (AUC) while calibration by Hosmer-Lemeshow test and predicted versus observed remission ratio.

RESULTS

At 1 year after surgery, 71.9% diabetes remission (HbA1c < 6.0 off medication) and 61.4% excess weight loss were observed. Individual metabolic surgery, ABCD, DiaRem, Advanced-DiaRem, DiaBetter, Ana et al., and Dixon et al. models showed excellent discrimination power (AUC > 0.8). In calibration, all models overestimated diabetes remission from 5 to 30% but did not lose their goodness of fit.

CONCLUSION

This is the first comprehensive external validation of current risk prediction models of diabetes remission at 1 year after SG. Seven models showed excellent predicting power, and scoring models were recommended more because of their easy utility.

Prospective randomized controlled trial comparing the efficacy and safety of Roux-en-Y gastric bypass and one-anastomosis gastric bypass (the RYSA trial): trial protocol and interim analysis

INTRODUCTION

There is a lack of prospective studies comparing Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB). Also, the effects of bariatric surgery and weight loss need a deeper understanding through metabolic studies. We describe the trial protocol and interim analysis of a prospective randomized controlled study comparing RYGB and OAGB: the RYSA trial.

MATERIALS AND METHODS

In total, 120 bariatric patients will be randomized between RYGB and OAGB in two academic centers. All patients will be followed up for 10 years with analysis and measurements of weight, comorbidities, blood tests, body composition and questionnaires. Extensive metabolic analyses (mixed meal tests, energy expenditure, biopsies of muscle and subcutaneous fat, urine, saliva and fecal samples) will be carried out in the Obesity Research Unit, University of Helsinki, for all patients treated at the Helsinki University Hospital (80 patients) at baseline, 6 months and 12 months. Bile reflux will be studied for the OAGB group at the Helsinki University Hospital at 6 months with gastroscopy and scintigraphy.

RESULTS

At an interim analysis at 3 months (half-way) through recruitment (30 RYGB and 30 OAGB patients) there have been no deaths and no intensive care unit admittances. One patient in both groups required additional gastroscopy, with anastomosis dilatation in the RYGB group but with no additional intervention in the OAGB group.

CONCLUSION

The trial can be safely carried out. Recruitment is estimated to be complete by the end of 2019.

TRIAL REGISTRATION

Clinical Trials Identifier NCT02882685. Registered on August 30th 2016.

Bariatric surgery and type 2 diabetes

Type 2 diabetes is primarily managed with lifestyle modifications, self-monitoring of blood glucose, and medication. The goal is to maintain A1C less than 7% in most patients and prevent damage to other organs such as the kidneys and heart. Patients who are obese and cannot achieve normal blood glucose levels despite diet, exercise, and multiple medications may be considered for bariatric surgery. The Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have been shown to improve A1C, reduce weight, and reduce the number of medications patients need for diabetes management. Comorbidities such as hyperlipidemia and hypertension also may improve. This article describes types of bariatric surgery, proper selection of surgical candidates, patient education, and the postoperative patient management necessary for long-term success in improving blood glucose control.

WEIGHT LOSS COMPARISON AFTER SLEEVE AND ROUX-EN-Y GASTRIC BYPASS: SYSTEMATIC REVIEW

INTRODUCTION

Bariatric surgery is currently the gold standard treatment for obesity. The two most accomplished surgeries are the Roux-en-Y gastric bypass and the sleeve gastrectomy, and controversies exist in which is better.

OBJECTIVE

To compare the two techniques in relation to weight loss with at least five years of follow-up.

METHODS

Search in Medline, PubMed, Embase, SciElo, Lilacs, Cochrane databases from 2001 (beginning of vertical gastrectomy) until 2018, using the following headings: "sleeve" or "sleeve gastrectomy" combined with "gastric bypass" or "Roux-en-Y gastric bypass", "weight loss" and "clinical trial". Criteria for inclusion of articles were patients aged between 18 and 65 years; clinical trial; comparison between the two techniques; minimum five-year follow-up; outcome with weight loss assessment.

RESULTS

The initial search identified 1940 articles, of which 185 publications were identified as clinical trials. One hundred and forty-one were excluded, 67 because they did not compare the two techniques, 57 not addressed weight loss and 17 were repeated articles. Thirty-four studies were retrieved for a more detailed analysis; 36 studies were excluded due to a follow-up of less than five years, and another compared the mini-gastric bypass. In total, seven studies were included in the systematic review, but there was no significant difference in three of them.

CONCLUSION

The gastric bypass had a greater weight loss than the vertical gastrectomy in all the evaluated studies.

BARIATRIC SURGERY IN BRAZILIAN PUBLIC HEALTH SYSTEM: THE GOOD, THE BAD AND THE UGLY, OR A LONG WAY TO GO. YELLOW SIGN!

BACKGROUND

In Brazil, there has been a significant increase in obesity rates in all age groups. Data from 2017 show that obesity affects 19% of the population. Due to the magnitude of the problem, public health policies have aimed to prevent complications related to obesity by increasing the offerfor bariatric surgeries.

AIM

To analyze the current status of bariatric surgery performed in the Brazilian public health system, including data from macroregions and also the effect of digestive surgery training on the number of procedures.

METHODS

The database of the public health registry (DATASUS) was assessedbetween 2008 and 2018 for descriptive analysis of data and evaluation of the selected parameters. The main surgical techniques, comorbidities, mortality and the costs profile of the system were evaluated.

RESULTS

There was a 339% increase in the number of bariatric surgeries in the period evaluated. Gastric bypass was performed in 94% of cases whereas sleeve in 2.4%. Other techniques were used in 3.6%. There were discrepancies in the number of surgeries performed in different regions of the country.

CONCLUSION

There was a considerable advance in the number of bariatric surgeries performed by the public health system between 2008 and 2018. However, there is a need to increase the offer of this service and alsospecialized training, as well as a correction in the distribution of these procedures in the national territory to achieve integrality among its users.

Cost-Effectiveness of Bariatric Surgery versus Medication Therapy for Obese Patients with Type 2 Diabetes in China: A Markov Analysis

AIMS/INTRODUCTION

The present study estimated the cost-effectiveness of bariatric surgery versus medication therapy for the management of recently diagnosed type 2 diabetes mellitus (T2DM) in obese patients from a Chinese health insurance payer perspective.

MATERIALS AND METHODS

A Markov model was established to compare the 40-year time costs and quality-adjusted life-years (QALYs) between bariatric surgery and medication therapy. The health-care costs in the bariatric surgery group, proportion of patients in each group with remission of diabetes, and state transition probabilities were calculated based on observed resource utilization from the hospital information system (HIS). The corresponding costs in the medication therapy group were derived from the medical insurance database. QALYs were estimated from previous literature. Costs and outcomes were discounted 5% annually.

RESULTS

In the base case analysis, bariatric surgery was more effective and less costly than medication therapy. Over a 40-year time horizon, the mean discounted costs were 86,366.55 RMB per surgical therapy patient and 113,235.94 CNY per medication therapy patient. The surgical and medication therapy patients lived 13.46 and 10.95 discounted QALYs, respectively. Bariatric surgery was associated with a mean health-care savings of 26,869.39 CNY and 2.51 additional QALYs per patient compared to medication therapy. Uncertainty around the parameter values was tested comprehensively in sensitivity analyses, and the results were robust.

CONCLUSIONS

Bariatric surgery is a dominant intervention over a 40-year time horizon, which leads to significant cost savings to the health insurance payer and increases in health benefits for the management of recently diagnosed T2DM in obese patients in China.

The Effects of Bariatric Surgery on Type 2 Diabetes in Asian Populations: a Meta-analysis of Randomized Controlled Trials

BACKGROUND

To evaluate the effects of bariatric surgery on patients with type 2 diabetes through comparing Asian and non-Asian populations according to follow-up time.

METHODS

In this meta-analysis of randomized controlled trials (RCTs), we searched PubMed databases for relevant articles. A meta-analysis was undertaken of 37 eligible RCTs.

RESULTS

Diabetes remission rates among Asian populations were similar to those of non-Asian populations at 1 year (95% confidence interval (CI) 0.519 [0.417, 0.619] vs 0.571 [0.316, 0.794], respectively) but were found to be higher in Asian populations at 2 years compared to non-Asian populations (95% CI 0.672 [0.469, 0.826] vs 0.563 [0.220, 0.855], respectively). Asian populations showed greater reductions in HbA1c (- 3.512 [- 2.726, - 4.299], - 3.001 [- 1.433, - 4.569], and - 3.345 [- 2.267, - 4.423]) than non-Asian populations (- 2.129 [- 1.821, - 2.438], - 2.301 [- 1.881, - 2.722], and - 2.107 [- 1.941, - 2.273]) at 1, 2, and 5 years, respectively. Asian populations also showed greater reductions of fasting plasma glucose than non-Asian populations, and these effects were prominent at 3- and 5-year follow-up (Asian populations, - 83.297 [- 73.264, - 93.331]; non-Asian populations, - 54.288 [- 37.409, - 71.166] at 3 years; Asian populations, - 99.014 [- 82.239, - 115.788]; non-Asian populations, - 45.756 [- 21.892, - 69.621] at 5 years).

CONCLUSIONS

Bariatric surgery is more successful in diabetes remission and glucose outcome improvement in Asian populations with type 2 diabetes than in non-Asian populations, even over long-term follow-up periods. Bariatric surgery can be considered an effective treatment option and may present an appropriate opportunity to improve the prognosis for Asian patients with type 2 diabetes.

Bariatric Surgery in the Treatment of Type 2 Diabetes

PURPOSE OF REVIEW

We seek to characterize the impact of bariatric surgery on diabetes mellitus by recalling its history, examining the clinical data, exploring the putative mechanisms of action, and anticipating its future.

RECENT FINDINGS

Results of clinical trials reveal that bariatric surgery induces remission of diabetes in 33-90% of individuals at 1-year post-treatment versus 0-39% of medically managed. Remission rates decrease over time but remain higher in surgically treated individuals. Investigations have revealed numerous actions of surgery including effects on intestinal physiology, neuronal signaling, incretin hormone secretion, bile acid metabolism, and microbiome changes. Bariatric surgery improves control of diabetes through both weight-dependent and weight-independent actions. These various mechanisms help explain the difference between individuals treated surgically vs. medically. They also explain differing effects of various bariatric surgery procedure types. Understanding how surgery affects diabetes will help optimize utilization of the therapy for both disease prevention and treatment.

Long-term outcomes of macrovascular diseases and metabolic indicators of bariatric surgery for severe obesity type 2 diabetes patients with a meta-analysis

There is currently no detailed evidence for the long-term effects of bariatric surgery on severely obese with type 2 diabetes, such as the risk of myocardial infarction and stroke. In order to provide evidence on the risks of macrovascular diseases and metabolic indicators of bariatric surgery follow-up for more than five years, we searched in the Cochrane library, Pubmed, and EMBASE databases from the earliest studies to January 31, 2019. Randomized clinical trials or cohort studies compared bariatric surgery and conventional medical therapy for long-term incidence of macrovascular events and metabolic outcomes in severely obese patients with T2DM. Fixed-effects and random-effects meta-analyses were performed to pool the relative risks (RRs), hazard ratios (HRs) and weighted mean difference (WMD). Publication bias and heterogeneity were examined. Four RCTs and six cohort studies were finally involved in this review. Patients in the bariatric surgery group as compared to the conventional treatment group had lower incidence of macrovascular complications (RR = 0.43, 95%CI = 0.27~0.70), cardiovascular events (CVEs) (HR = 0.52, 95%CI = 0.39~0.71), and myocardial infarction (MI) (RR = 0.40, 95%CI = 0.26~0.61). At the same time, the results demonstrate that bariatric surgery is associated with better weight and better glycemic control over the long-term than non-surgical therapies, and reveal that different surgical methods have different effects on various metabolic indicators. Bariatric surgery significantly decreases macrovascular complications over the long term and is associated with greater weight loss and better intermediate glucose outcomes among T2DM patients with severe obesity as compared to patients receiving only conservative medical measures.

Proceedings of the 2017 ASPEN Research Workshop-Gastric Bypass: Role of the Gut

The goal of the National Institutes of Health-funded American Society for Parenteral and Enteral Nutrition 2017 research workshop (RW) "Gastric Bypass: Role of the Gut" was to focus on the exciting research evaluating gut-derived signals in modulating outcomes after bariatric surgery. Although gastric bypass surgery has undoubted positive effects, the mechanistic basis of improved outcomes cannot be solely explained by caloric restriction. Emerging data suggest that bile acid metabolic pathways, luminal contents, energy balance, gut mucosal integrity, as well as the gut microbiota are significantly modulated after bariatric surgery and may be responsible for the variable outcomes, each of which was rigorously evaluated. The RW served as a timely and novel academic meeting that brought together clinicians and researchers across the scientific spectrum, fostering a unique venue for interdisciplinary collaboration among investigators. It promoted engaging discussion and evolution of new research hypotheses and ideas, driving the development of novel ameliorative, therapeutic, and nonsurgical interventions targeting obesity and its comorbidities. Importantly, a critical evaluation of the current knowledge regarding gut-modulated signaling after bariatric surgery, potential pitfalls, and lacunae were thoroughly addressed.

An evaluation of liraglutide including its efficacy and safety for the treatment of obesity

Introduction: The prevalence of obesity is increasing worldwide and associated conditions, particularly type 2 diabetes mellitus (T2DM), also show increasing prevalence. Lifestyle intervention should be the first line of management for obesity but additional pharmacotherapy is often required and bariatric surgery is appropriate in more severe cases. Drugs acting as glucagon-like peptide-1 receptor agonists (GLP-1RAs) developed for the management of T2DM reduce body weight and liraglutide is the first GLP-1RA to be approved for the treatment of obesity in patients with and without T2DM.Areas covered: In this review of relevant published material, the authors summarize the pharmacokinetics, pharmacodynamics, clinical efficacy and safety of liraglutide for the treatment of obesity.Expert opinion: Liraglutide effectively reduces body weight and body fat through mechanisms involving reduced appetite and lowered energy intake, independent of its glucose-lowering effects. Like most of the other medications currently available for obesity, liraglutide has some common adverse effects, although generally not serious ones. Liraglutide has additional benefits in reducing cardiovascular events in patients with T2DM but the cost and the need for daily injections may limit its use in obesity. Newer GLP-1RAs, such as semaglutide, or other drugs in development for obesity may have advantages over liraglutide.

Gastric bypass versus sleeve gastrectomy in patients with type 2 diabetes (Oseberg): a single-centre, triple-blind, randomised controlled trial

BACKGROUND

For patients with obesity and type 2 diabetes, weight loss improves insulin sensitivity and β-cell function, and can induce remission of diabetes. The comparative efficacy of various bariatric procedures for the remission of type 2 diabetes has not been fully elucidated. We aimed to compare the effects of the two most common bariatric procedures, gastric bypass and sleeve gastrectomy, on remission of diabetes and β-cell function.

METHODS

We conducted a single-centre, triple-blind, randomised trial at Vestfold Hospital Trust (Tønsberg, Norway), in which patients (aged ≥18 years) with type 2 diabetes and obesity were randomly assigned (1:1) to receive gastric bypass or sleeve gastrectomy (the Oseberg study). Randomisation was performed with a computerised random number generator and a block size of 10. Treatment allocation was masked from participants, study personnel, and outcome assessors and was concealed with sealed opaque envelopes. Surgeons used identical skin incisions during both surgeries and were not involved in patient follow-up. The primary clinical outcome was the proportion of participants with complete remission of type 2 diabetes (HbA_1c of ≤6·0% [42 mmol/mol] without the use of glucose-lowering medication) at 1 year after surgery. The primary physiological outcome was disposition index (a measure of β-cell function) at 1 year after surgery, as assessed by an intravenous glucose tolerance test. Primary outcomes were analysed in the intention-to-treat and per-protocol populations. This trial is ongoing and closed to recruitment, and is registered with ClinicalTrials.gov, NCT01778738.

FINDINGS

Between Oct 15, 2012, and Sept 1, 2017, 1305 patients who were preparing for bariatric surgery were screened, of whom 319 consecutive patients with type 2 diabetes were assessed for eligibility. 109 patients were enrolled and randomly assigned to gastric bypass (n=54) or sleeve gastrectomy (n=55). 107 (98%) of 109 patients completed 1-year follow-up, with one patient in each group withdrawing after surgery (per-protocol population). In the intention-to-treat population, diabetes remission rates were higher in the gastric bypass group than in the sleeve gastrectomy group (risk difference 27% [95% CI 10 to 44]; relative risk [RR] 1·57 [1·14 to 2·16], p=0·0054); results were similar in the per-protocol population (risk difference 27% [95% CI 10 to 45]; RR 1·57 [1·14 to 2·15], p=0·0036). In the intention-to-treat population, disposition index increased in both groups (between-group difference 55 [-111 to 220], p=0·52); results were similar in the per-protocol population (between-group difference 21 [-214 to 256], p=0.86). In the gastric bypass group, ten of 54 participants had early complications and 17 of 53 had late side-effects. In the sleeve gastrectomy group, eight of 55 participants had early complications and 22 of 54 had late side-effects. No deaths occurred in either group.

INTERPRETATION

Gastric bypass was found to be superior to sleeve gastrectomy for remission of type 2 diabetes at 1 year after surgery, and the two procedures had a similar beneficial effect on β-cell function. The use of gastric bypass as the preferred bariatric procedure for patients with obesity and type 2 diabetes could improve diabetes care and reduce related societal costs.

FUNDING

Morbid Obesity Centre, Vestfold Hospital Trust.

Investigating Intestinal Glucagon After Roux-en-Y Gastric Bypass Surgery

CONTEXT

After Roux-en-Y gastric bypass (RYGB) surgery, postprandial plasma glucagon concentrations have been reported to increase. This occurs despite concomitant improved glucose tolerance and increased circulating plasma concentrations of insulin and the glucagon-inhibiting hormone glucagon-like peptide 1 (GLP-1).

OBJECTIVE

To investigate whether RYGB-induced hyperglucagonemia may be derived from the gut.

DESIGN AND SETTING

Substudy of a prospective cross-sectional study at a university hospital in Copenhagen, Denmark.

PARTICIPANTS

Morbidly obese individuals undergoing RYGB (n = 8) with or without type 2 diabetes.

INTERVENTIONS

Three months before and after RYGB, participants underwent upper enteroscopy with retrieval of gastrointestinal mucosal biopsy specimens. Mixed-meal tests were performed 1 week and 3 months before and after RYGB.

MAIN OUTCOME MEASURES

The 29-amino acid glucagon concentrations in plasma and in mucosal gastrointestinal biopsy specimens were assessed using mass spectrometry-validated immunoassays, and a new monoclonal antibody reacting with immunoreactive glucagon was used for immunohistochemistry.

RESULTS

Postprandial plasma concentrations of glucagon after RYGB were increased. Expression of the glucagon gene in the small intestine increased after surgery. Glucagon was identified in the small-intestine biopsy specimens obtained after, but not before, RYGB. Immunohistochemically, mucosal biopsy specimens from the small intestine harbored cells costained for GLP-1 and immunoreactive glucagon.

CONCLUSION

Increased concentrations of glucagon were observed in small-intestine biopsy specimens and postprandially in plasma after RYGB. The small intestine harbored cells immunohistochemically costaining for GLP-1 and glucagon-like immunoreactivity after RYGB. Glucagon derived from small-intestine enteroendocrine l cells may contribute to postprandial plasma concentrations of glucagon after RYGB.

Endoscopic duodenal mucosal resurfacing improves glycaemic and hepatic indices in type 2 diabetes: 6-month multicentre results

Insulin resistance is a core pathophysiological defect underscoring type 2 diabetes mellitus (T2DM) and non-alcoholic fatty liver disease (NAFLD). Both conditions improve with duodenal exclusion surgery. Duodenal mucosal resurfacing (DMR) is an endoscopic intervention developed to treat metabolic disease which has been shown to improve glycaemia in patients with poorly controlled T2DM. Herein, we aimed to further analyse the effects of DMR on hepatic and metabolic parameters in this patient cohort.

METHODS

Eighty-five patients with T2DM who received endoscopic DMR treatment were enrolled from 5 centres and followed up for 6 months. We assessed safety in all patients. Efficacy was evaluated in patients who received at least 9 cm of duodenal ablation (n = 67). Endpoints included HbA1c, fasting plasma glucose, weight and aminotransferase levels. Metabolomic analysis was conducted in a subgroup (n = 14). Data were analysed using paired t test or ANOVA for repeated measures with Bonferroni correction and correction for initial weight loss if applicable.

RESULTS

The DMR procedure was completed with no intraprocedural complications in the entire cohort. HbA1c was lower 6 months after DMR than at baseline (7.9 ± 0.2% vs. 9.0 ± 0.2% [mean ± SE], p ≪0.001). Fasting plasma glucose was also significantly lower 6 months after DMR compared to baseline (161 ± 7 mg/dl vs. 189 ± 6 mg/dl, p = 0.005). Body weight decreased slightly. At 6 months, alanine aminotransferase had decreased from 41 ± 3 IU/L to 29 ± 2 IU/L (p ≪0.001) and aspartate aminotransferase had decreased from 30 ± 2 IU/L to 23 ± 1 IU/L (p ≪0.001). Metabolomic analysis demonstrated that DMR had key lipid-lowering, insulin-sensitizing and anti-inflammatory effects, as well as increasing antioxidant capacity. Mean FIB-4 was also markedly decreased.

CONCLUSION

Hydrothermal ablation of the duodenum by DMR elicits a beneficial metabolic response in patients with T2DM. DMR also improves hepatic indices, potentially through an insulin-sensitizing mechanism. These encouraging data deserve further evaluation in randomized controlled trials.

LAY SUMMARY

Hydrothermal duodenal mucosal resurfacing (DMR) is an endoscopic technique designed to treat metabolic disease through ablation of the duodenal mucosa. DMR is a safe procedure which improves glycaemia and hepatic indices in patients with type 2 diabetes mellitus. DMR is an insulin-sensitizing intervention which can be complementary to lifestyle intervention approaches and pharmacological treatments aimed at preserving the pancreas and liver from failure. DMR is a potential therapeutic solution for patients with type 2 diabetes and fatty liver disease.

The ketogenic diet: Pros and cons

Diets have been at the center of animated debates for decades and many claims have been made in one direction or the other by supporters of opposite camps, often with limited evidence. At times emphasis has been put on a single new aspect that the previous diets had overlooked and the new one was to embrace in order to improve weight loss and well-being. Unfortunately, very few randomized clinical trials involving diets have addressed the combined question of weight loss and cardiovascular outcomes. The recently introduced ketogenic diet requires a rigorous limitation of carbohydrates while allowing a liberal ingestion of fats (including saturated fats) and has generated a flurry of interest with many taking the pro position and as many taking the cons position. The ketogenic diet causes a rapid and sensible weight loss along with favourable biomarker changes, such as a reduction in serum hemoglobin A1c in patients with diabetes mellitus type 2. However, it also causes a substantial rise in low density lipoprotein cholesterol levels and many physicians are therefore hesitant to endorse it. In view of the popular uptake of the keto diet even among subjects not in need of weight loss, there is some preoccupation with the potential long-term consequences of a wide embrace of this diet by large segments of the population. On the contrary, numerous lines of evidence show that plant-based diets are associated with reduction in oncological and cardiovascular diseases and a prolonged life span. The debate reproduced in this article took place during a continuous medical education program between two cardiologists with largely differing views on the matter of effectiveness, sustainability, and safety of the ketogenic diet compared to alternative options.

[What is the position of bariatric surgery in the treatment of non-alcoholic steatohepatitis?]

Bariatric surgery is indicated for patients with BMI≥35kg/m² and associated steatohepatitis. Bariatric surgery induces NASH disappearance for nearly 80% of patients after 1 year of follow up. Bariatric surgery is associated with low morbidity and mortality if patients are well selected. Bariatric surgery is contraindicated in patients with cirrhosis. Long-term data are needed to determine the risk of recurrence of NASH. The extension of indications for bariatric surgery to patients with BMI less than 35kg/m² will depend on the results of randomized trials.

Effect of a low energy diet, containing a high protein, probiotic condensed yogurt, on biochemical and anthropometric measurements among women with overweight/obesity: A randomised controlled trial

BACKGROUND & AIMS

The aim of this study was to determine the effect of low energy diet containing condensed processed yogurt (Kashk), as a high protein, calcium and probiotic enriched product, on glycemic control, lipid profile, anthropometric measurements and blood pressure among women with overweight/obesity.

METHODS

70 women with overweight/obesity were randomly assigned to receive either a low energy diet contained 50 g of Kashk (intervention group) or a low energy diet without Kashk (control group) for 8 weeks. Anthropometric, blood pressure and biochemical measurements were obtained before and after the intervention.

RESULTS

Between-group comparisons showed that the intervention group significantly decreased triglycerides (P = 0.013) and low density lipoprotein cholesterol (P = 0.049) levels relative to the control group. Significantly greater reductions in body mass index (P = 0.018), fat percent (P = 0.037) and waist circumference (P = 0.047) were observed in the intervention group compared to control. Within-group comparisons revealed significant reductions in systolic blood pressure (P = 0.035) and weight (P = 0.005) in the intervention group.

CONCLUSIONS

Long-term consumption of Kashk, as a high protein and calcium product enriched with probiotic that is accompanied by a low energy diet, might have beneficial effects on anthropometric and biochemical indices, though more cross-over and parallel blinded trials with placebo groups are needed to confirm these results. (The clinical trial registration number is IRCT2013042913163N1).

New insight into the mechanisms of ectopic fat deposition improvement after bariatric surgery

Non-alcoholic fatty-liver disease (NAFLD) is frequent in obese patients and represents a major risk factor for the development of diabetes and its complications. Bariatric surgery reverses the hepatic features of NAFLD. However, its mechanism of action remains elusive. We performed a comprehensive analysis of the mechanism leading to the improvement of NAFLD and insulin resistance in both obese rodents and humans following sleeve-gastrectomy (SG). SG improved insulin sensitivity and reduced hepatic and monocyte fat accumulation. Importantly, fat accumulation in monocytes was well comparable to that in hepatocytes, suggesting that Plin2 levels in monocytes might be a non-invasive marker for the diagnosis of NAFLD. Both in vitro and in vivo studies demonstrated an effective metabolic regeneration of liver function and insulin sensitivity. Specifically, SG improved NAFLD significantly by enhancing AMP-activated protein kinase (AMPK) phosphorylation and chaperone-mediated autophagy (CMA) that translate into the removal of Plin2 coating lipid droplets. This led to an increase in lipolysis and specific amelioration of hepatic insulin resistance. Elucidating the mechanism of impaired liver metabolism in obese subjects will help to design new strategies for the prevention and treatment of NAFLD.

Highlights from Selected Cardiovascular Disease Prevention Studies Presented at the 2019 European Society of Cardiology Congress

PURPOSE OF REVIEW

This review intends to highlight selected cardiovascular disease (CVD) prevention studies presented at the 2019 European Society of Cardiology (ESC) Congress.

RECENT FINDINGS

Results from the Inclisiran for Subjects with ASCVD or ASCVD-risk Equivalent and Elevated Low-density Lipoprotein Cholesterol (ORION-11) trial validate inclisiran's ability to significantly lower low-density lipoprotein cholesterol (LDL-C) levels in at-risk individuals on a background of maximally tolerated statin therapy. The EVOlocumab for Early Reduction of LDL-cholesterol Levels in Patients With Acute Coronary Syndromes (EVOPACS) trial provide additional support that a PCSK9 inhibitor can be initiated safely and effectively early after an acute coronary syndrome. A sub-study of the Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) trial provides further support for stratification of secondary prevention patients to help define the magnitude of risk reduction associated with PCSK9 inhibitor therapy. A post hoc analysis from the Aspirin in Reducing Events in the Elderly (ASPREE) trial suggest that any benefits associated with aspirin utilizing a risk-based approach are overwhelmed by increased bleeding risk. In a large retrospective cohort study of patients with diabetes mellitus and obesity, the addition of metabolic (weight loss) surgery to standard care led to greater improvement in CVD outcomes, weight loss, and glycemic control. Results from the Prospective Urban Rural Epidemiology (PURE) study demonstrate that while hypertension and dyslipidemia exert additive lifelong effects on CVD risk, other less established risk factors such as low education, household pollution, and poor diet also have a strong impact on CVD outcomes, especially in middle- and low-income countries. Finally, in the Heart Outcomes Prevention and Evaluation (HOPE) 4 trial, a comprehensive model of care adapted to address multiple barriers of specific communities led to substantial improved blood pressure (BP) control, medication use, and adherence. A number of studies presented at the 2019 ESC Congress reinforced the value of preventative interventions in CVD risk reduction.

The Role of Bariatric Surgery on Diabetes and Diabetic Care Compliance

PURPOSE OF REVIEW

Bariatric surgery is a durable and long-term solution to treat both obesity and its associated comorbidities, specifically type 2 diabetes mellitus (T2DM). Many studies have demonstrated the benefits of bariatric surgery on T2DM, but weight recidivism along with recurrence of comorbidities can be seen following these procedures. Patient compliance post-bariatric surgery is linked to weight loss outcomes and comorbidity improvement/resolution. The role of compliance with respect to T2DM medication in bariatric patients specifically has not recently been examined. This article seeks to review the role of bariatric surgery on short- and long-term resolution of T2DM, recurrence, and compliance with T2DM medication following bariatric surgery.

RECENT FINDINGS

Seven randomized control trials have examined metabolic surgery versus medical therapy in glycemic control in patients meeting criteria for severe obesity. Six out of seven studies demonstrate a significant advantage in the surgical arms with regards to glycemic control, as well as secondary endpoints such as weight loss, serum lipid levels, blood pressure, renal function, and other parameters. While patient compliance with lifestyle modifications post-bariatric surgery is linked to weight loss outcomes, there are no studies to date that directly evaluate the role of lifestyle modifications and T2DM medication adherence in the management of T2DM post-bariatric surgery. Bariatric surgery is an effective treatment option to achieve long-term weight loss and resolution of obesity-related medical comorbidities, specifically T2DM. Patient compliance to lifestyle modifications post-bariatric surgery is linked to weight loss outcomes and comorbidity resolution. The role of diabetic care compliance in bariatric patient outcomes, however, is poorly understood. Further studies are needed to elucidate the predictors and associated risk factors for non-compliance in this patient population.

A rodent model of partial intestinal diversion: a novel metabolic operation

BACKGROUND

Metabolic surgery is safe and the most effective therapy for obesity and its co-morbidities. New procedures may allow for better tailoring of metabolic surgery to the individual patient.

OBJECTIVE

To evaluate the impact, comparative effectiveness, and mechanisms of the partial intestinal diversion (PID), vertical sleeve gastrectomy (VSG), and the combination of PID and VSG on weight and glucose regulation.

SETTING

University research facility, United States.

METHODS

Three cohorts of high-fat diet-induced obese male rats were randomized to distal PID (DPID), proximal PID (PPID), VSG, VSG and DPID (VSG/DPID), or sham operation (Sham). Animals were followed for 11 (cohort 1) or 10 (cohorts 2 and 3) weeks. Outcomes included weight and composition, food intake, glucose metabolism, lipids, bile acids, and energy balance. Statistical comparisons were performed using Tukey's multiple comparison test applied to analysis of variance.

RESULTS

DPID and not PPID resulted in significant weight and body fat reductions relative to Sham. Improved glucose tolerance was seen in all surgical groups though this reached statistical significance for only DPID and VSG compared with Sham. Improvements in baseline glucose and insulin, corresponding insulin resistance, and plasma lipids were noted in DPID compared with Sham. Though the magnitude of weight and body composition changes and metabolic benefit tended to be larger for VSG relative to DPID, it only reached statistical significance for lipids. VSG and VSG/DPID resulted in similar outcomes. Markedly reduced food intake occurred after VSG and more modestly after DPID. Stool caloric content was higher in DPID relative to all groups.

CONCLUSIONS

DPID is an effective metabolic operation resulting in notable weight and fat loss and metabolic improvement relative to sham-operated rodents. Interestingly, combining VSG with DPID added little additional benefit to the effects of VSG.

Is it worth it? Determining the health benefits of sleeve gastrectomy in patients with a body mass index <35 kg/m2

BACKGROUND

Criteria for undergoing sleeve gastrectomy (SG) is restricted among patients with a body mass index (BMI) <35 kg/m².

OBJECTIVES

To determine if low-BMI patients experience similar health benefits after SG compared with patients with a BMI ≥35 kg/m².

SETTING

Teaching and nonteaching hospitals in Michigan.

METHODS

Patients with a BMI <35 kg/m² at the time of primary SG were identified between 2006 and 2018 (n = 1073, 2.4%). Patient characteristics, 30-day risk-adjusted complication rates, and patient reported outcomes were compared with all patients who underwent SG with a BMI ≥35 kg/m² (n = 44,511, mean BMI 46.7 kg/m²).

RESULTS

Low-BMI patients were more likely to be older (50.7 versus 45.4 yr, P < .0001), have diabetes (36.7 versus 30.9%, P < .0001), hypertension (54.2% versus 51.0%, P = .0372), and hyperlipidemia (57.1% versus 44.8%, P < .0001). Both groups had comparable rates of discontinuation of medications for hypertension (59.7% versus 54.1%, P = .0570), hyperlipidemia (54.3% versus 52.2%, P = .5537), and diabetes (oral, 79.2% versus 78.1%, P = .7294; insulin, 64.2% versus 62.2%, P = .7438). However, low-BMI patients were more likely to achieve a healthy BMI (i.e., BMI ≤25 kg/m²; 36.3% versus 6.01%, P < .0001), and had higher body image scores (50.6 versus 42.4, P < .0001).

CONCLUSIONS

Despite being older and with higher rates of metabolic disease, low-BMI patients reported high-resolution rates for diabetes, hypertension, and hyperlipidemia (>50%) and were more likely to achieve a healthy weight after SG. Abolishing the BMI threshold for SG among patients with metabolic disease should be considered.

Biliopancreatic Diversion Induces Greater Metabolic Improvement Than Roux-en-Y Gastric Bypass

Diabetes remission is greater after biliopancreatic diversion (BPD) than Roux-en-Y gastric bypass (RYGB) surgery. We used a mixed-meal test with ingested and infused glucose tracers and the hyperinsulinemic-euglycemic clamp procedure with glucose tracer infusion to assess the effect of 20% weight loss induced by either RYGB or BPD on glucoregulation in people with obesity (ClinicalTrials.gov number: NCT03111953). The rate of appearance of ingested glucose into the circulation was much slower, and the postprandial increases in plasma glucose and insulin concentrations were markedly blunted after BPD compared to after RYGB. Insulin sensitivity, assessed as glucose disposal rate during insulin infusion, was ∼45% greater after BPD than RYGB, whereas β cell function was not different between groups. These results demonstrate that compared with matched-percentage weight loss induced by RYGB, BPD has unique beneficial effects on glycemic control, manifested by slower postprandial glucose absorption, blunted postprandial plasma glucose and insulin excursions, and greater improvement in insulin sensitivity.

Management of Diabetes in Patients Undergoing Bariatric Surgery

PURPOSE OF REVIEW

The number of bariatric surgeries for patients with type 1 or type 2 diabetes continues to grow. Clinicians are challenged to choose therapies that reach glycemic targets without inducing adverse effects in post-bariatric patients without published guidelines. This review evaluates data supporting the best strategies for diabetes management in patients undergoing bariatric surgery.

RECENT FINDINGS

Though few clinical trials have evaluated the safety and effectiveness of different glucose-lowering therapies following bariatric surgery, remission of diabetes or reduced medications is an established benefit of bariatric surgery. Adverse events including diabetic ketoacidosis in post-bariatric patients on sodium-glucose co-transporter 2 (SGLT2) inhibitors or inadequate insulin have been reported in patient's with both type 1 and type 2 diabetes. Metformin, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, SGLT2 inhibitors, insulin, and sulfonylureas have been used successfully in the perioperative period for other surgeries and guidelines recommend adjusting the doses of these medications especially in the perioperative period. Clinicians should favor weight-neutral or weight-loss promoting therapies in post-bariatric surgery patients such as medical nutrition therapy, metformin, GLP-1 agonists, SGLT2 inhibitors, and DPP-4 inhibitors.

Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care

The objective of the study is to provide evidence-based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow-up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print-friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high-quality evidence and warrant further research. These areas are highlighted in the paper.

Duration of type 2 diabetes and remission rates after bariatric surgery in Sweden 2007-2015: A registry-based cohort study

BACKGROUND

Although bariatric surgery is an effective treatment for type 2 diabetes (T2D) in patients with morbid obesity, further studies are needed to evaluate factors influencing the chance of achieving diabetes remission. The objective of the present study was to investigate the association between T2D duration and the chance of achieving remission of T2D after bariatric surgery.

METHODS AND FINDINGS

We conducted a nationwide register-based cohort study including all adult patients with T2D and BMI ≥ 35 kg/m2 who received primary bariatric surgery in Sweden between 2007 and 2015 identified through the Scandinavian Obesity Surgery Registry. The main outcome was remission of T2D, defined as being free from diabetes medication or as complete remission (HbA1c < 42 mmol/mol without medication). In all, 8,546 patients with T2D were included. Mean age was 47.8 ± 10.1 years, mean BMI was 42.2 ± 5.8 kg/m2, 5,277 (61.7%) were women, and mean HbA1c was 58.9 ± 17.4 mmol/mol. The proportion of patients free from diabetes medication 2 years after surgery was 76.6% (n = 6,499), and 69.9% at 5 years (n = 3,765). The chance of being free from T2D medication was less in patients with longer preoperative duration of diabetes both at 2 years (odds ratio [OR] 0.80/year, 95% CI 0.79-0.81, p < 0.001) and 5 years after surgery (OR 0.76/year, 95% CI 0.75-0.78, p < 0.001). Complete remission of T2D was achieved in 58.2% (n = 2,090) at 2 years, and 46.6% at 5 years (n = 681). The chance of achieving complete remission correlated negatively with the duration of diabetes (adjusted OR 0.87/year, 95% CI 0.85-0.89, p < 0.001), insulin treatment (adjusted OR 0.25, 95% CI 0.20-0.31, p < 0.001), age (adjusted OR 0.94/year, 95% CI 0.93-0.95, p < 0.001), and HbA1c at baseline (adjusted OR 0.98/mmol/mol, 95% CI 0.97-0.98, p < 0.001), but was greater among males (adjusted OR 1.57, 95% CI 1.29-1.90, p < 0.001) and patients with higher BMI at baseline (adjusted OR 1.07/kg/m2, 95% CI 1.05-1.09, p < 0.001). The main limitations of the study lie in its retrospective nature and the low availability of HbA1c values at long-term follow-up.

CONCLUSIONS

In this study, we found that remission of T2D after bariatric surgery was inversely associated with duration of diabetes and was highest among patients with recent onset and those without insulin treatment.

Will medications that mimic gut hormones or target their receptors eventually replace bariatric surgery?

Bariatric surgery is currently the most effective therapeutic modality through which sustained beneficial effects on weight loss and metabolic improvement are achieved. During recent years, indications for bariatric surgery have been expanded to include cases of poorly controlled type 2 (T2DM) diabetes mellitus in lesser extremes of body weight. A spectrum of the beneficial effects of surgery is attributed to robust changes of postprandial gut peptide responses that are observed post operatively. Consolidated knowledge regarding gut peptide physiology as well as emerging new evidence shedding light on the mode of action of previously overlooked gut hormones provide appealing potential obesity and T2DM therapeutic perspectives. The accumulation of evidence from the effect of exogenous administration of native gut peptides alone or in combinations to humans as well as the development of mimetic agents exerting agonistic effects on combinations of gut hormone receptors pave the way for future integrated gut peptide-based treatments, which may mimic the effects of bariatric surgery.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Utilizing Untargeted Ion Mobility-Mass Spectrometry To Profile Changes in the Gut Metabolome Following Biliary Diversion Surgery

Obesity and obesity-related disorders are a global epidemic affecting over 10% of the world's population. Treatment of these diseases has become increasingly challenging and expensive. The most effective and durable treatment for Class III obesity (body mass index ≥35 kg/m²) is bariatric surgery, namely, Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy. These procedures are associated with increased circulating bile acids, molecules that not only facilitate intestinal fat absorption but are also potent hormones regulating numerous metabolic pathways. We recently reported on a novel surgical procedure in mice, termed distal gallbladder bile diversion to the ileum (GB-IL_dist), that emulates the altered bile flow after RYGB without other manipulations of gastrointestinal anatomy. GB-IL_dist improves oral glucose tolerance in mice made obese with high-fat diet. This is accompanied by fat malabsorption and weight loss, which complicates studying the role of elevated circulating bile acids in metabolic control. A less aggressive surgery in which the gallbladder bile is diverted to the proximal ileum, termed GB-IL_prox, also improves glucose control but is not accompanied by fat malabsorption. To better understand the differential effects achieved by these bile diversion procedures, an untargeted ultraperformance liquid chromatography-ion mobility-mass spectrometry (UPLC-IM-MS) method was optimized for fecal samples derived from mice that have undergone bile diversion surgery. Utilizing the UPLC-IM-MS method, we were able to identify dysregulation of bile acids, short-chain fatty acids, and cholesterol derivatives that contribute to the differential metabolism resulting from these surgeries.

Lorcaserin and Renal Outcomes in Obese and Overweight Patients in the CAMELLIA-TIMI 61 Trial

BACKGROUND

Obesity is thought to increase renal hyperfiltration, thereby increasing albuminuria and the progression of renal disease. The effect of pharmacologically mediated weight loss on renal outcomes is not well-described. Lorcaserin, a selective serotonin 2C receptor agonist that promotes appetite suppression, led to sustained weight loss without any increased risk for major adverse cardiovascular (CV) events in the CAMELLIA-TIMI 61 trial (Cardiovascular and Metabolic Effects of Lorcaserin in Overweight and Obese Patients-Thrombolysis in Myocardial Infarction 61).

METHODS

CAMELLIA-TIMI 61 randomly assigned 12 000 overweight or obese patients with or at high risk for atherosclerotic CV disease to lorcaserin or placebo on a background of lifestyle modification. The primary renal outcome was a composite of new or worsening persistent micro- or macroalbuminuria, new or worsening chronic kidney disease, doubling of serum creatinine, end-stage renal disease, renal transplant, or renal death.

RESULTS

At baseline, 23.8% of patients had an estimated glomerular filtration rate (eGFR) <60 mL·min^-1·1.73 m^-2 and 19.0% had albuminuria (urinary albumin:creatinine ratio ≥30 mg/g). Lorcaserin reduced the risk of the primary renal composite outcome (4.2% per year versus 4.9% per year; hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.79-0.96; P=0.0064). The benefit was consistent across subpopulations at increased baseline CV and renal risk. Lorcaserin improved both eGFR and urinary albumin:creatinune ratio within the first year after randomization. The effect of lorcaserin on weight, hemoglobin A1c, and systolic blood pressure was consistent regardless of baseline renal function. Likewise, there was no excess in cardiovascular events in patients assigned to lorcaserin in comparison with placebo, regardless of renal function. After adjustment for baseline characteristics, those with evidence of kidney disease were at increased risk of major CV events. Compared with patients with an eGFR ≥90 mL·min^-1·1.73 m^-2, those with an eGFR 60-90 and those <60 mL·min^-1·1.73 m-2 had HRs of 1.25 (95% CI, 1.01, 1.56) and 1.51 (95% CI, 1.17, 1.95), respectively ( P for trend 0.0015). Likewise, compared with patients with no albuminuria (<30 mg/g), those microalbuminuria and those with macroalbuminuria had HRs of 1.46 (95% CI, 1.22, 1.74) and 2.10 (95% CI, 1.58, 2.80), respectively ( P for trend <0.0001).

CONCLUSIONS

Renal dysfunction was associated with increased CV risk in overweight and obese patients. When added to diet and lifestyle, lorcaserin reduced the rate of new-onset or progressive renal impairment in comparison with placebo.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02019264.

Factors Mediating Type 2 Diabetes Remission and Relapse after Gastric Bypass Surgery

BACKGROUND

Defining factors associated with remission and relapse of type 2 diabetes (T2D) after Roux-en-Y gastric bypass (RYGB) can allow targeting modifiable factors. We investigated factors associated with T2D remission and relapse after RYGB.

STUDY DESIGN

We conducted a retrospective review of consecutive patients with T2D who underwent RYGB between 1993 and 2017. T2D remission was defined as medication discontinuation and/or hemoglobin A1c <6.5%. Relapse was defined as recurrence medication use and/or hemoglobin A1c ≥6.5%. Independent correlates of T2D remission and relapse were identified using logistic regression.

RESULTS

Six hundred and twenty-one patients (aged 46.7 ± 10.6 years; 30% on insulin; BMI 49.8 ± 8.3 kg/m²) had at least 1-year follow-up. Median follow-up was 4.9 years (range 1 to 23.6 years). Prevalence of T2D remission was 74% at 1 year, 73% from 1 to 3 years, 63% between 3 and 10 years, and 47% beyond 10 years. Ninety-three percent of remissions occurred within 3 years of RYGB, 25% relapsed. Median time to relapse was 5.3 years (interquartile range 3 to 7.8 years) after remission. Higher 1-year percentage total body weight loss, lack of preoperative insulin use, and younger age at operation were independently associated with T2D remission. Preoperative insulin use, lower percentage total body weight loss at 1 year, and greater percentage total body weight regain after 1 year were independently associated with T2D relapse.

CONCLUSIONS

This longitudinal retrospective analysis shows that preoperative insulin use and age, 1-year weight loss, and regain after that influence T2D remission and relapse after RYGB. Referring patients at a younger age, before insulin is needed, and optimizing weight loss and preventing weight regain after RYGB can improve the rates and durability of T2D remission.

Impact on Dyslipidemia After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Improvement of dyslipidemia is an important benefit of bariatric surgery. The benefits of laparoscopic sleeve gastrectomy (LSG) among dyslipidemia are still a matter of debate.

METHODS

We conducted a retrospective descriptive study between 2010 and 2013. Obese patients undergoing LSG, with recorded dyslipidemia at admission and a follow-up for at least 1 year, were included for analysis. Demographic characteristics, medication in use, and a complete lipid profile were collected before surgery. After surgery, weight was controlled at 1, 3, 6, and 12 months. Lipid profile was re-evaluated 1 year after surgery. Patients were divided according to weight loss into two groups: (A) adequate weight loss and (B) inadequate weight loss. Lipid profile evolution was then compared between groups.

RESULTS

One hundred seven patients met the inclusion criteria. Pre-op mean BMI was 45.13 ± 7.5 kg/m². One year after LSG, mean BMI was 30.6 ± 7.1 kg/m² with a change in BMI of 11.5 ± 6.6 kg/m², a %TWL of 26.9 ± 13.5%, and a %EWL of 60.3 ± 36.6%. Hypercholesterolemia and hypertriglyceridemia remission was achieved in 45 and 86% of the patients and improved in another 19 and 4% respectively. Seventy-four percent improved HDL levels. LDL levels improved in 39% and remitted in 37%. Medication was discontinued in 43.7%. HDL increase and LDL, TG, and non-HDL-C decrease were significantly greater in group A.

CONCLUSIONS

LSG produces an improvement in lipid profile, with a significant increase in HDL and a decrease in LDL, triglycerides, and non-HDL-C.

Long-Term Impact of Bariatric Surgery on Renal Outcomes at a Community-Based Publicly Funded Bariatric Program: The Regina Bariatric Study

Background:

Obesity is recognized as an independent risk factor for chronic kidney disease through multiple direct and indirect biological pathways. Bariatric surgery is a proven, effective method for sustained weight loss. However, there is a relative paucity of data on the impact of bariatric surgery on renal outcomes.

Objective:

The primary objective was to evaluate the change in urine albumin/creatinine ratio (ACR) in patients undergoing bariatric surgery, at 12 months after the procedure. Secondary objectives were to determine the changes in ACR at (6 and 24 months), estimated glomerular filtration rate (eGFR; 6, 12, and 24 months), and hemoglobin A1c (HbA1c); 12 and 24 months) after the procedure.

Design:

This observational retrospective cohort study included consecutive obese patients who underwent bariatric surgery.

Setting:

Provincial Bariatric Surgery Clinic at the Regina General Hospital, Saskatchewan.

Patients:

This study includes 471 consecutive obese adult patients who underwent bariatric surgery between 2008 and 2015.

Measurements:

We studied the impact of bariatric surgery on body mass index (BMI), renal outcomes (urine ACR and eGFR) and metabolic outcomes (fasting glucose, total cholesterol, low-density lipoprotein, triglycerides, and HbA1c) in 471 patients.

Methods:

Patients were followed for 2 years postsurgery in the bariatric clinic. Mixed linear models that accounted for the repeated nature of the data were used to access changes in outcomes over time.

Results:

Patients were predominantly female (81%) with a mean age (±SD) of 46 ± 10 years. Most patients (87%) had a BMI > 40 kg/m² and 81% of the patients underwent Roux-en-Y gastric bypass. The mean BMI decreased from 47.7 ± 7.8 kg/m² at baseline to 37.1 ± 7.9 kg/m² at 6 months and 34.8 ± 8.8 kg/m² at 12 months. In a subcohort of patients with microalbuminuria, ACR showed an improvement from a median [interquartile] value of 5.1 [3.7-7.5] mg/mmol at baseline to 2.3 [1.2-3.6] mg/mmol at 6 months (P = .007), to 1.4 [0.9-3.7] mg/mmol at 2-year follow-up (P < .001). Similarly, eGFR increased in patients with microalbuminuria from 109 ± 10 mL/min/1.73 m² at baseline to 120 ± 36 mL/min/1.73 m² at 2-year follow-up (P = .013). There were statistically significant reductions in triglycerides, fasting glucose, and HbA1c.

Limitations:

This was a retrospective chart review, with the lack of a control group. Patients with eGFR less than 60 mL/min/1.73 m² were not considered for surgery, and we had to measure renal outcomes predominantly on the presence of proteinuria.

Conclusions:

Our results suggest bariatric surgery significantly decreased weight and consequently improved renal and metabolic outcomes (eGFR, ACR, fasting glucose, cholesterol, and triglycerides) in patients with elevated BMI.

Endobarrier as a Pre Bariatric Surgical Intervention in High-Risk Patients: a Feasibility Study

Background

Obesity surgery mortality risk scoring system (OS-MRS) classifies patients into high, intermediate and low risk, based on age, body mass index, sex and other comorbidities such as hypertension and history of pulmonary embolism. High-risk patients not only have a higher mortality but are more likely to develop post-operative complications necessitating intervention or prolonged hospital stay following bariatric surgery. Endoscopically placed duodenal-jejunal bypass sleeve (Endobarrier) has been designed to achieve weight loss and improve glycaemic control in morbidly obese patients with clinically proven effectiveness.

The aim of this study was to assess if pre-operative insertion of endobarrier in high-risk patients can decrease morbidity and length of stay after bariatric surgery.

Materials and Methods

Between 2012 and 2014, a cohort of 11 high-risk patients had an Endobarrier inserted (E&BS group) for 1 year prior to definitive bariatric surgery. These patients were compared against a similar group undergoing primary bariatric surgery (PBS group) during same duration. The two groups were matched for age, gender, body mass index, comorbidities, surgical procedure and OS-MRS using propensity score matching. Outcome measures included operative time, morbidity, length of stay, intensive therapy unit (ITU) stay, readmission rate, percentage excess weight loss (%EWL) and percentage total weight loss (%TWL).

Results

Patient characteristics and OS-MRS were similar in both groups (match tolerance 0.1). There was no significant difference in total length of stay, readmission rate, %EWL and %TWL. Operative time, ITU stay, post-operative complications and severity of complications were significantly less in the E&BS group (p < 0.05) with significant likelihood of planned ITU admissions in the PBS group (p < 0.05).

Conclusion

Endobarrier could be considered as a pre bariatric surgical intervention in high-risk patients. It may result in improved post-operative outcomes in high-risk bariatric patients.

Mid-term 4-Year Outcomes with Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy Surgery at a Single US Center

BACKGROUND

Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of Roux-en-Y duodenal switch (RYDS). Long-term data on this operation is lacking in the literature. We reviewed our mid-term data of this RYDS modification.

PURPOSE

To analyze the outcomes with SADI-S at 4 years.

METHODS

Data from patients who underwent a primary SADI-S procedure performed by three surgeons at a single institution from June 2013 through February 2018 were retrospectively reviewed. All revision bariatric surgeries were excluded. Regression analyses were performed for all follow-up weight loss data.

RESULTS

There were 437 patients in our database. The pre-operative mean body mass index (BMI) was 49.8 ± 8.8 kg/m². The 30-day complication rate was 7.7%. The 30-day readmission, reoperation, and mortality rates were 1.8, 1.3, and 0.2%, respectively. The long-term complication rate was 10.9%. Seventy-nine patients were 4 years post SADI-S surgery and follow-up was possible for 44 patients (55.7%). At 4 years, patients had an average change in BMI of 18.1 ± 6 units with an excess weight loss (EWL) of 85.7 ± 27.3%. At 4 years, 97.6% patients were able to maintain HbA1c < 6% with or without the use of diabetic medication. There was a statistically significant difference between most of the pre-operative and post-operative nutritional data.

CONCLUSIONS

SADI-S is a safe and effective procedure in both short- and mid-term data points. Diabetes resolution and weight loss appear similar to traditional RYDS and better than RYGB.

Thirteen-Year Experience of Laparoscopic Sleeve Gastrectomy: Surgical Risk, Weight Loss, and Revision Procedures

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been validated as a safe and effective treatment for morbid obesity. However, data of the long-term outcome remains lacking.

METHODS

A total of 1759 LSG was performed as primary bariatric procedure from 2005 to 2017 with mean age of 35.2 ± 10.3 years old (14-71), female 69.7%, mean body mass index (BMI) 37.9 ± 7.7 kg/m², and mean waist width 113.7 ± 17.9 cm. All patients were evaluated and managed under a strict multidisciplinary team approach. A retrospective analysis of a prospective bariatric database and telephone interview of patients who defaulted clinic follow-up at 10 years was conducted.

RESULTS

The mean operating time, intraoperative blood, and hospital stay of LSG were 121.5 ± 36.5 min, 40.8 ± 69.7 ml, and 2.8 ± 2.7 days, respectively. The 30-day postoperative major complication occurred in 25 (1.4%) patients. The major complication rate was 15% at first year and 0% at the last year. The follow-up rate at 1, 5 and 10 years were 89.3%, 52.1 and 64.4%. At postoperative 1, 5, and 10 years, the mean percentage of total weight loss (%TWL) and excess weight loss (EWL%) of LSG patients were 33.4, 28.3, and 26.6% and 92.2, 80.1, and 70.5%, respectively. The mean BMI became 27, 26.2, and 27.1 kg/m² at postoperative 1, 5, and 10 years. At follow-up, a total 69 patients needed surgical revision due to reflux disease (n = 45), weight regain (n = 19), persistent diabetes (n = 2), and chronic fistula (n = 3). The type of revision procedures were hiatal repair and gastropexy (n = 29), Roux-en Y gastric bypass (RYGB) (n = 23), and single anastomosis bypass (n = 17) with median time to revision 33 months (range 3-62). At 10 years, the overall revision rate was 21.5% (14/65) and 11(16.9%) of 65 patients were converted to RYGB. The other 54 patients remained at LSG anatomy, but 45% of them required proton pump inhibitor for reflux symptoms.

CONCLUSIONS

Our results showed that primary LSG is a durable primary bariatric procedure with sustained weight loss and a high resolution of comorbidities at 10 years, but about half the patients had de novo GERD. The need for conversion to RYGB was 16.9% at 10 years.

Sustained Improvements in Glucose Metabolism Late After Roux-En-Y Gastric Bypass Surgery in Patients with and Without Preoperative Diabetes

To describe glucose metabolism in the late, weight stable phase after Roux-en-Y Gastric Bypass (RYGB) in patients with and without preoperative type 2 diabetes we invited 55 RYGB-operated persons from two existing cohorts to participate in a late follow-up study. 44 (24 with normal glucose tolerance (NGT)/20 with type 2 diabetes (T2D) before surgery) accepted the invitation (median follow-up 2.7 [Range 2.2–5.0 years]). Subjects were examined during an oral glucose stimulus and results compared to preoperative and 1-year (1 y) post RYGB results. Glucose tolerance, insulin resistance, beta-cell function and incretin hormone secretion were evaluated. 1 y weight loss was maintained late after surgery. Glycemic control, insulin resistance, beta-cell function and GLP-1 remained improved late after surgery in both groups. In NGT subjects, nadir glucose decreased 1 y after RYGB, but did not change further. In T2D patients, relative change in weight from 1 y to late after RYGB correlated with relative change in fasting glucose and HbA1c, whereas relative changes in glucose-stimulated insulin release correlated inversely with relative changes in postprandial glucose excursions. In NGT subjects, relative changes in postprandial nadir glucose correlated with changes in beta-cell glucose sensitivity. Thus, effects of RYGB on weight and glucose metabolism are maintained late after surgery in patients with and without preoperative T2D. Weight loss and improved beta-cell function both contribute to maintenance of long-term glycemic control in patients with type 2 diabetes, and increased glucose stimulated insulin secretion may contribute to postprandial hypoglycemia in NGT subjects.

Roux-en-Y Gastric Bypass Is More Effective than Sleeve Gastrectomy in Improving Postprandial Glycaemia and Lipaemia in Non-diabetic Morbidly Obese Patients: a Short-term Follow-up Analysis

PURPOSE

We aimed to compare the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on postprandial glucose and lipid metabolism in addition to weight loss and fasting metabolic profile, in non-diabetic patients undergoing bariatric surgery.

METHODS

Seventy-one patients were consecutively recruited and studied preoperatively, 3 and 6 months after surgery. Of these, 28 underwent RYGB (7 males, age 38 ± 9 years, BMI 46.9 ± 5.0 kg/m²), and 43 SG (9 males, age 38 ± 9 years, BMI 50.2 ± 7.0 kg/m²). A semi-liquid mixed meal was consumed, and blood samples were taken before, and every 30 min after meal ingestion up to 180 min postprandially, for measurement of glucose, insulin, and lipids. The overall postprandial response was assessed as area under the concentration-time curve (AUC).

RESULTS

Baseline metabolic parameters were similar between RYGB and SG. Both groups experienced comparable weight loss, and a similar improvement in fasting glucose, insulin, and insulin resistance. Total and LDL cholesterol levels were lower at 6 months after RYGB compared to SG, while there was no difference in HDL cholesterol or triglycerides. Glucose AUC was lower after RYGB compared to SG at both 3 (p = 0.008) and 6 months (p = 0.016), without any difference in postprandial insulin response. Triglyceride AUC was also lower in RYGB vs. SG at 3 and 6 months (p ≤ 0.001).

CONCLUSIONS

RYGB is superior to SG in improving postprandial glycaemia and lipaemia and cholesterol profile 6 months postoperatively in non-diabetic, severely obese patients. These findings imply procedure-specific effects, such as the malabsorptive nature of RYGB, and less likely a different incretin postoperative response.

The Reduction of Visceral Adipose Tissue after Roux-en-Y Gastric Bypass Is more Pronounced in Patients with Impaired Glucose Metabolism

Purpose

Visceral adipose tissue (VAT) is associated with cardiometabolic risk factors and insulin resistance. The physiological mechanisms underlying the benefits of Roux-en-Y gastric bypass surgery (RYGB) on glucose metabolism remain incompletely understood. The impact of RYGB on VAT was assessed among three groups of patients stratified by their glucose tolerance before surgery.

Methods

Forty-four obese women were categorized into normoglycemia (n = 21), impaired glucose tolerance (IGT, n = 18) and diabetes (n = 5) before surgery. Body composition measured by dual-energy X-ray absorptiometry (DXA) was performed before surgery, 6 months and 12 months after.

Results

The three groups had comparable mean age (mean 38.6 ± SD 9.9) and BMI at baseline (41.9 ± 4.3 kg/m²). After 12 months, total weight loss (mean 35.1% ± 7.5) and excess weight loss (91.1% ± 25.1) were similar between groups. Pre-surgery mean VAT was significantly higher in diabetes (mean 2495 ± 616 g) than in normoglycemia (1750 ± 617 g, p = 0.02). The percentage of VAT to total body fat was significantly higher in diabetes (mean 4.4% ± 0.9) compared to normoglycemia (2.9% ± 0.8, p = 0.003). Twelve months after surgery, VAT loss was significantly greater among patients with diabetes (mean 1927 ± 413 g) compared to normoglycemia (1202 ± 450, p = 0.009).

Conclusions

RYGB leads to important VAT loss, and this loss is greater in patients with diabetes prior to surgery. As VAT is associated with insulin resistance, this reduction may account for the profound impact of this surgery on glucose metabolism.

Early improvement in patient reported disability after bariatric surgery

BACKGROUND

Bariatric surgery is an effective intervention for managing morbid obesity. Little evidence has been reported regarding objective assessments of patient disability after surgery. The World Health Organization Disability Assessment Score 2.0 is a validated tool for assessing the level of disability after surgery, including assessment of difficulty with activities of daily living, social activities, and overall functioning.

OBJECTIVE

Evaluate patient disability after bariatric surgery at a tertiary care medical center.

SETTING

University hospital, United States.

METHODS

An institutional review board-approved prospective cohort study included patients undergoing primary bariatric surgery; patients undergoing a revisional procedure were excluded. Patient-reported disability was assessed using World Health Organization Disability Assessment Score 2.0, administered preoperatively and at 1 and 3 months after surgery. Disability scores (maximum of 48 reflecting extreme disability, minimum of 0) were analyzed for statistically significant trends.

RESULTS

One hundred ten patients enrolled in the study (76% female, 24% male) with 46% sleeve gastrectomy and 54% Roux-en-Y gastric bypass. Preoperative body mass index was 47.08 ± 7.6 (n = 110). The preoperative World Health Organization Disability Assessment Score scores were 6.66 ± 6.10 (n = 110). For those who completed both preoperative and 1-month surveys (n = 53), the scores were 6.60 ± 5.76 and 4.04 ± 4.68, respectively (P < .001). Those completing both preoperative and 3-month surveys (n = 53) had scores of 6.08 ± 5.48 and 2.38 ± 3.74, respectively (P < .001).

CONCLUSION

We report early improvement in disability with a validated tool at 1 and 3 months after bariatric surgery. This equates to global disability in this cohort improving from the 75th percentile of the population norm preoperatively to the 50th percentile at 3 months. Further studies are needed to determine if this is sustained long-term.

An Analysis of Mid-Term Complications, Weight Loss, and Type 2 Diabetes Resolution of Stomach Intestinal Pylorus-Sparing Surgery (SIPS) Versus Roux-En-Y Gastric Bypass (RYGB) with Three-Year Follow-Up

BACKGROUND

For many years, the Roux-en-Y Gastric Bypass (RYGB) was considered a good balance of complications and weight loss. According to several short-term studies, single anastomosis duodenal switch or stomach intestinal pylorus sparing surgery (SIPS) offers similar weight loss to RYGB with fewer complications and better diabetes resolution. No one has substantiated mid-term complication and nutritional differences between these two procedures. This paper seeks to compare complication and nutritional outcomes between RYGB and SIPS.

METHODS

A retrospective analysis of 798 patients who either had SIPS or RYGB from 2010 to 2016. Complications were gathered for each patient. Nutritional outcomes were measured for each group at 1, 2, and 3 years. Regression analysis was applied to interpolate each patient's weight at 3, 6, 9, 12, 18, 24, and 36 months. These were then compared with t tests, Fisher's exact tests, and chi-squared tests.

RESULTS

RYGB and SIPS have statistically similar weight loss at 3, 6, 9, 12, and 36 months. They statistically differ at 18 and 24 months. At 36 months, there is a trend for weight loss difference. There were only statistical differences in nutritional outcomes between the two procedures with calcium at 1 and 3 years and vitamin D at 1 year. There were statistically significantly more long-term class IIIb-V complications, class I-IIIa complications, reoperations, ulcers, small bowel obstructions, nausea, and vomiting with the RYGB than the SIPS.

CONCLUSION

With comparable weight loss and nutritional outcomes, SIPS has fewer short- and long-term complications than RYGB and better type 2 diabetes resolution rates.