Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial

Microvascular Outcomes in Patients With Diabetes After Bariatric Surgery Versus Usual Care: A Matched Cohort Study

Background

Bariatric surgery improves glycemic control in patients with type 2 diabetes mellitus (T2DM), but less is known about microvascular outcomes.

Objective

To investigate the relationship between bariatric surgery and incident microvascular complications of T2DM.

Design

Retrospective matched cohort study from 2005 to 2011 with follow-up through September 2015.

Setting

4 integrated health systems in the United States.

Participants

Patients aged 19 to 79 years with T2DM who had bariatric surgery (n = 4024) were matched on age, sex, body mass index, hemoglobin A1c level, insulin use, diabetes duration, and intensity of health care use up to 3 nonsurgical participants (n = 11 059).

Intervention

Bariatric procedures (76% gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) compared with usual care.

Measurements

Adjusted Cox regression analysis investigated time to incident microvascular disease, defined as first occurrence of diabetic retinopathy, neuropathy, or nephropathy.

Results

Median follow-up was 4.3 years for both surgical and nonsurgical patients. Bariatric surgery was associated with significantly lower risk for incident microvascular disease at 5 years (16.9% for surgical vs. 34.7% for nonsurgical patients; adjusted hazard ratio [HR], 0.41 [95% CI, 0.34 to 0.48]). Bariatric surgery was associated with lower cumulative incidence at 5 years of diabetic neuropathy (7.2% for surgical vs. 21.4% for nonsurgical patients; HR, 0.37 [CI, 0.30 to 0.47]), nephropathy (4.9% for surgical vs. 10.0% for nonsurgical patients; HR, 0.41 [CI, 0.29 to 0.58]), and retinopathy (7.2% for surgical vs. 11.2% for nonsurgical patients; HR, 0.55 [CI, 0.42 to 0.73]).

Limitation

Electronic health record databases could misclassify microvascular disease status for some patients.

Conclusion

In this large, multicenter study of adults with T2DM, bariatric surgery was associated with lower overall incidence of microvascular disease (including lower risk for neuropathy, nephropathy, and retinopathy) than usual care.

Primary Funding Source

National Institute of Diabetes and Digestive and Kidney Diseases.

Impact of bariatric surgery on cardiovascular and renal complications of diabetes: a focus on clinical outcomes and putative mechanisms

INTRODUCTION

Cardiovascular and renal disease accounts for a substantial proportion of the morbidity and mortality associated with obesity and type 2 diabetes mellitus (T2DM). Bariatric surgery is associated with improved long-term cardiovascular and renal outcomes.

AREAS COVERED

All major case-control, cohort, and randomized controlled trial studies of bariatric surgery in adults with T2DM were screened and data on prespecified cardiovascular and renal outcomes collated. Bariatric surgery reduces all-cause mortality and risk of cardiovascular disease, albuminuria and progressive chronic kidney disease. Patients with poorer glycemic control and established microvascular disease preoperatively may stand to benefit the most from the surgical approach. Reduced sympathetic drive, remission of glomerular hypertension, enhanced natriuresis, gut microbiota shifts, reduced systemic and renal inflammation, improved lipoprotein profiles, and reductions in chronic cardiac remodeling may all be implicated.

EXPERT COMMENTARY

Ongoing RCTs of bariatric surgery selectively recruiting patients with class 1 obesity and established microvascular complications of diabetes will help to better characterize which subgroups of patients benefit most from this effective therapy.

Laparoscopic Sleeve Gastrectomy: To Suture or not to Suture Staple Line?

Objective

To assess the outcome and safety of staple line over-sewing for patients undergoing laparoscopic sleeve gastrectomy (LSG).

Study design and location

Retrospective descriptive analysis conducted at Shifa International Hospital Islamabad.

Materials and methods

Consecutive patients undergoing LSG as a treatment for morbid obesity from October 2013 to December 2016 were included in the study after approval from the ethical review board. Patients were divided into two groups: group A who underwent reinforcement using Vicryl 2.0 and group B where no reinforcement was done.

Results

A total of 225 patients underwent LSG between October 2013 and December 2016, including 147 females (65.4%) and 78 males (34.6%). Both groups were comparable in terms of age, body mass index (BMI) and gender distribution (p-value more than 0.05). There was one leak in group A (1.36%), none in group B. The bleeding rate was 4.3% in group A and 2.7% in group B.

Conclusion

This was a retrospective analysis of all the patients who underwent LSG, and it was observed that there was no added benefit of sewing the staple line in terms of rate of bleeding and leak.

Combination Therapies for Obesity

The objective of this review is to examine advances in the development of combination therapies for the treatment of obesity beyond diet or lifestyle interventions. Experimental combination pharmacotherapies include combinations of pramlintide and phentermine as well as amylin and bupropion-naltrexone. Incretin and pancreatic hormones generally inhibit upper gastrointestinal motor functions, and combinations showing efficacy in obesity are coadministration of glucagon-like peptide-1 (GLP-1) with glucagon, a unimolecular dual incretin of PEGylated GLP-1/GIP coagonist, the combination of GLP-1 and PYY_3-36, and, in proof of concept studies, combined infusions of GLP-1, peptide YY, and oxyntomodulin. Among bariatric procedures, repeat intragastric balloon (IGB) treatments are more efficacious than IGB plus diet, and endoscopic intervention can enhance the effects of Roux-en-Y gastric bypass when weight regain occurs. A first trial has provided promising results with combination of IGB plus the GLP-1 analog, liraglutide, compared to the balloon alone. Thus, combination therapies for the treatment of obesity hold promise for introduction into clinical practice.

Comparative Characteristics of Patients with Type 2 Diabetes Mellitus Treated by Bariatric Surgery Versus Medical Treatment: a Multicentre Analysis of 277,862 Patients from the German/Austrian DPV Database

INTRODUCTION

Bariatric surgery is a well-established treatment option for serious obesity and concomitant type 2 diabetes mellitus (T2DM). In this analysis, we investigated predictors for bariatric surgery in everyday clinical practice.

MATERIALS AND METHODS

In the DPV-registry, patients with T2DM from Germany and Austria treated by bariatric surgery were compared to non-surgery controls by descriptive statistics and regression analysis.

RESULTS

Among 277,862 patients with T2DM, 0.07% underwent bariatric surgery. Surgery patients were predominantly female [61.20%], younger [median age (Q1;Q3) 54.74(47.40;61.61) vs. 70.04 (60.36;77.58) years] and had a longer diabetes duration [11.21 (7.15;17.93) vs. 8.36 (2.94;14.91) years]. They had a higher BMI [40.02 vs. 30.61 kg/m², adjusted p < 0.0001] and a slightly lower HbA1c [7.25 vs. 7.56%, adjusted p < 0.05]. There was a trend using more often insulin therapy (52.79 vs.50.08%, n.s.) with no difference in insulin dose/kg × day [0.56 vs. 0.58, n.s.]. Sleeve gastrectomy was performed most frequently, followed by Roux-en-Y gastric bypass, gastric banding, gastric balloon and others. A 2-year follow-up data in 29 patients demonstrated significant reductions in BMI [45.23 to 38.00 kg/m², p < 0.005] and HbA1c [7.98 to 6.98%, p < 0.005], and a trend for reduced insulin requirements [62.07 vs. 44.83%, n.s.].

CONCLUSION

Despite favourable 2-year outcomes, bariatric surgery is still used rarely in patients with T2DM and obesity. BMI rather than metabolic control seems to represent the major selector for or against bariatric surgery in T2DM.

Efficacy of video-based education program in improving metabolic surgery perception among patients with obesity and diabetes

BACKGROUND

Metabolic surgery remains underutilized despite its efficacy and safety. Poor perception of surgery has been cited as one of the major reasons.

OBJECTIVES

Evaluate current patient perceptions about metabolic surgery and measure the impact a video-based education program has on changing the perceptions of patients diagnosed with obesity and type 2 diabetes.

SETTING

A university hospital in the United States.

METHODS

A prospective interventional study was performed at an endocrinology clinic. Patients were asked to complete surveys evaluating their perception of metabolic surgery before and after watching a short educational video.

RESULTS

A total of 51 patients were recruited; almost all patients (98%) attempted weight loss in the past, and approximately 90.1% voiced dissatisfaction with their current weight. The video-based education program was effective in improving the patient's perception of the efficacy and safety with regard to surgery. In addition, the proportion of patients with overall positive impression toward metabolic surgery increased from 22.5% to 53.1% (P < .01) and those willing to undergo surgical consultation increased from 41.7% to 51.0% (P < .01). Among those that remained unwilling, fear of surgery in general was the most commonly voiced reason (31.4%), with safety (27.5%) and cost of metabolic surgery (27.5%) being equally concerning.

CONCLUSIONS

Most patients with obesity and type 2 diabetes held negative impressions of metabolic surgery due to its perceived risk profile. A video-based educational intervention may improve patients' perception and increase their willingness for surgical referral. Future trials with a broader sample and longer follow-up could provide answers to its efficacy in increasing metabolic surgery accessibility.

Patients and investigators prefer measures of absolute risk in subgroups for pragmatic randomized trials

OBJECTIVES

Pragmatic randomized trials are important tools for shared decision-making, but no guidance exists on patients' preferences for types of causal information. We aimed to assess preferences of patients and investigators toward causal effects in pragmatic randomized trials.

STUDY DESIGN AND SETTING

We (a) held three focus groups with patients (n = 23) in Boston, MA; (b) surveyed (n = 12) and interviewed (n = 5) investigators with experience conducting pragmatic trials; and (c) conducted a systematic literature review of pragmatic trials (n = 63).

RESULTS

Patients were distrustful of new-to-market medications unless substantially more effective than existing choices, preferred stratified absolute risks, and valued adherence-adjusted analyses when they expected to adhere. Investigators wanted both intention-to-treat and per-protocol effects but felt methods for estimating per-protocol effects were lacking. When estimating per-protocol effects, many pragmatic trials used inappropriate methods to adjust for adherence and loss to follow-up.

CONCLUSION

We made four recommendations for pragmatic trials to improve patient centeredness: (1) focus on superiority in effectiveness or safety, rather than noninferiority; (2) involve patients in specifying a priori subgroups; (3) report absolute measures of risk; and (4) complement intention-to-treat effect estimates with valid per-protocol effect estimates.

What Has Bariatric Surgery Taught Us About the Role of the Upper Gastrointestinal Tract in the Regulation of Postprandial Glucose Metabolism?

The interaction between the upper gastrointestinal tract and the endocrine system is important in the regulation of metabolism and of weight. The gastrointestinal tract has a heterogeneous cellular content and comprises a variety of cells that elaborate paracrine and endocrine mediators that collectively form the entero-endocrine system. The advent of therapy that utilizes these pathways as well as the association of bariatric surgery with diabetes remission has (re-)kindled interest in the role of the gastrointestinal tract in glucose homeostasis. In this review, we will use the changes wrought by bariatric surgery to provide insights into the various gut-pancreas interactions that maintain weight, regulate satiety, and limit glucose excursions after meal ingestion.

The impact of bariatric surgery on the resolution of obstructive sleep apnoea

OBJECTIVE

Obesity is associated with a high incidence of obstructive sleep apnoea (OSA). Bariatric surgery is postulated to lead to OSA resolution, but there is inconclusive evidence on its efficacy. We used objective measurements to determine the rate of resolution or improvement of OSA in patients who had bariatric procedures in our unit.

RESULTS

Data was analysed on all patients with OSA who underwent bariatric procedures [laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG)] between June 2012 and September 2016 in our unit. 47 patients (26.7%) were diagnosed with OSA. Mean age was 48.5 years. 63.8% were female. 43 required nocturnal continuous positive airway pressure (CPAP) support. Procedures were LRYGB (n = 26) and LSG (n = 21). Mean excess weight loss was 56.1%. Mean start apnoea-hypopnoea index (AHI) on CPAP was 6.4 events/hr and end AHI was 1.4 events/h. 14 patients (32.6%) had complete OSA resolution and 12 (27.9%) showed improvement in pressure support requirements. We demonstrated that 55.3% of patients had resolution or improvement in OSA following bariatric surgery. However, there was a high rate of non-attendance of follow-up appointments. Future efforts will involve analysis of the reasons for this to ensure more robust monitoring.

Optimisation of follow-up after metabolic surgery

Bariatric surgery has many benefits beyond weight loss, including improved control of glycaemia, blood pressure, and dyslipidaemia; hence, such surgery has been rebranded as metabolic surgery. The operations are, unfortunately, also associated with major surgical and medical complications. The medical complications include gastro-oesophageal reflux disease, malnutrition, and metabolic complications deriving from vitamin and mineral malabsorption. The benefits of surgery can be optimised by implementing specific protocols before and after surgery. In this Review, we discuss the assessment of the risk of major cardiac complications and severe obstructive sleep apnoea before surgery, and the provision of adequate lifelong postsurgery nutritional, vitamin, and mineral supplementation to reduce complications. Additionally, we examine the best antidiabetic medications to reduce the risk of hypoglycaemia after gastric bypass and sleeve gastrectomy, and the strategies to improve weight loss or reduce weight regain. Although optimising clinical pathways is possible to maximise metabolic benefits and reduce the risks of complications and micronutrient deficiencies, evolution of these strategies can further improve the risk-to-benefit ratio of metabolic surgery.

Altered glucose metabolism after bariatric surgery: What's GLP-1 got to do with it?

Bariatric surgery is an effective treatment for obesity. The two widely performed weight-loss procedures, Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG), alter postprandial glucose pattern and enhance gut hormone secretion immediately after surgery before significant weight loss. This weight-loss independent glycemic effects of GB has been attributed to an accelerated nutrient transit from stomach pouch to the gut and enhanced secretion of insulinotropic gut factors; in particular, glucagon-like peptide-1 (GLP-1). Meal-induced GLP-1 secretion is as much as tenfold higher in patients after GB compared to non-surgical individuals and inhibition of GLP-1 action during meals reduces postprandial hyperinsulinemia after GB two to three times more than that in persons without surgery. Moreover, in a subgroup of patients with the late complication of postprandial hyperinsulinemic hypoglycemia after GB, GLP1R blockade reverses hypoglycemia by reducing meal stimulated insulin secretion. The role of enteroinsular axis activity after SG, an increasingly popular alternative to GB, is less understood but, similar to GB, SG accelerates nutrient delivery to the intestine, improves glucose tolerance, and increases postprandial GLP-1 secretion. This review will focus on the current evidence for and against the role of GLP-1 on glycemic effects of GB and will also highlight differences between GB and SG.

Surgical treatment of obesity

Obesity prevalence continues to increase worldwide, as do the numerous chronic diseases associated with obesity, including diabetes, non-alcoholic fatty liver disease, dyslipidemia, and hypertension. The prevalence of bariatric surgery also continues to increase and remains the most effective and sustainable treatment for obesity. Over the last several years, numerous prospective and longitudinal studies have demonstrated the benefits of bariatric surgery on weight loss, mortality, and other chronic diseases. Even though the mechanisms underlying many of these beneficial effects remain poorly understood, surgical management of obesity continues to increase given its unmatched efficacy. In this commentary, we discuss recent clinical advancements as well as several areas needed for future research, including indications for bariatric and metabolic surgery, determination of responders and non-responders, metabolic surgery in non-obese individuals, and the evolving role of bariatric surgery in adolescents.

Bone Health After Bariatric Surgery

Bariatric surgery results in long-term weight loss and improvement or resolution in obesity-related comorbidities. However, mounting evidence indicates that it adversely affects bone health. This review summarizes clinical research findings about the impact of bariatric surgery on skeletal outcomes. The literature is the largest and strongest for the Roux-en-Y gastric bypass (RYGB) procedure, as RYGB was the most commonly performed bariatric procedure worldwide until it was very recently overtaken by the sleeve gastrectomy (SG). Because SG is a newer procedure, its skeletal effects have not yet been well defined. Epidemiologic studies have now demonstrated an increased risk of fracture after RYGB and biliopancreatic diversion with duodenal switch, both of which include a malabsorptive component. As these epidemiologic data have emerged, patient-oriented studies have elucidated the bone tissue-level changes that may account for the heightened skeletal fragility. Bariatric surgery induces early and dramatic increases in biochemical markers of bone turnover. A notable feature of recent patient-oriented clinical studies is the application of advanced skeletal imaging modalities; studies address the limitations of dual-energy X-ray absorptiometry (DXA) by using quantitative computed tomography (QCT)-based modalities to examine volumetric bone mineral density and compartment-specific density and microstructure. RYGB results in pronounced declines in bone mass at the axial skeleton demonstrated by DXA and QCT, as well as at the appendicular skeleton demonstrated by high-resolution peripheral quantitative computed tomography (HR-pQCT). RYGB has detrimental effects on trabecular and cortical microarchitecture and estimated bone strength. Skeletal changes after RYGB appear early and continue even after weight loss plateaus and weight stabilizes. The skeletal effects of bariatric surgery are presumably multifactorial, and mechanisms may involve nutritional factors, mechanical unloading, hormonal factors, and changes in body composition and bone marrow fat. Clinical guidelines address bone health and may mitigate the negative skeletal effects of surgery, although more research is needed to direct and support such guidelines. © 2018 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Laparoscopic Sleeve Gastrectomy for the Management of Type 1 Diabetes Mellitus

BACKGROUND

The prevalence of obesity is on a continuous rise worldwide, with major studies clearly correlating obesity with the development of chronic metabolic disorders including type 2 diabetes. Bariatric surgery has proven to be beneficial in the management of this condition; however, a limited number of studies exist on its effect on type 1 diabetes.

OBJECTIVE

The objective of this study is to evaluate the outcome of laparoscopic sleeve gastrectomy for the management of patients with type 1 diabetes (DM1).

SETTING

This is a retrospective cohort study conducted in a university hospital and private practice in Kuwait.

RESEARCH DESIGN AND METHODS

Analysis was conducted on 10 patients diagnosed with type 1 diabetes that underwent bariatric surgery from October 2008 until December 2016 at Amiri Hospital and Royale Hayat Hospital, Kuwait. Primary parameters included body mass index (BMI), % excess weight (%EWL) loss at follow-up, glycosylated hemoglobin (A1C), and basal insulin requirements. Total cholesterol readings and fasting blood glucose (FBS) levels were considered secondary outcomes. Statistical analysis of the data was carried out using Statistical Package for the Social Sciences (SPSS) software.

RESULTS

Mean BMI showed a reduction from 41.9 ± 5.4 to 31.4 ± 8.4 kg/m². Mean %EWL after the follow-up period was 74.4 ± 25.3%. A1C levels failed to show a significant difference 12 months post-op (p = 0.189). Cholesterol levels did not display a significant decrease either (p = 0.447). When it came to insulin requirements, a significant difference was perceived, with the mean number of units of insulin required dropping from 76.6 to 18.2 (p = 0.026). FBS readings also showed a drop from 15.1 ± 3.8 to 7.8 ± 2.9 mmol/L (p = 0.001).

CONCLUSIONS

Laparoscopic sleeve gastrectomy resulted in significant weight loss, comorbidity resolution as well as reduction in their insulin doses post-op. However, glycemic control does not seem to show significant improvement in these patients. Larger, more long-term studies are needed to reach a definite conclusion on this topic.

Roux-en-Y gastric bypass is an effective bridge to kidney transplantation: Results from a single center

Body mass index (BMI) > 35-40 kg/m² is often a contraindication, while Roux-en-Y gastric bypass (RYGB) is performed to enable kidney transplantation. This single-center retrospective study evaluated pre- and post-transplant outcomes of 31 morbidly obese patients with end-stage renal disease having RYGB before kidney transplantation between July 2009 and June 2014. Fourteen RYGB patients were subsequently transplanted. Nineteen recipients not having GB with a BMI ≥ 36 kg/m² at transplantation were used as historical controls. Mean BMI (±SE) before RYGB was 43.5 ± 0.7 kg/m² (range: 35.4-50.5 kg/m² ); 87.1% (27/31) achieved a BMI < 35 kg/m² . The percentage having improved diabetes/hypertension control was 29.0% (9/31); 25.8% (8/31) had complications (mostly minor) after RYGB. Among transplanted patients, blacks/Hispanics comprised 78.6% (11/14) and 84.2% (16/19) of RYGB and controls; 57.1% (8/14) and 63.2% (12/19) had a (mostly long-standing) pretransplant history of diabetes. While biopsy-proven acute rejection (BPAR) occurred significantly higher among RYGB vs control patients (6/14 vs 3/19, P = .03), patients developing T-cell BPAR were also significantly more likely to have a tacrolimus (TAC) trough level < 4.0 ng/mL within 3 weeks of T-cell BPAR (P = .0007). In Cox's model, the impact of having a TAC level < 4.0 ng/mg remained significant (P = .007) while the effect of RYGB was no longer significant (P = .13). Infections, graft, and patient survival were not significantly different. Despite obvious effectiveness in achieving weight loss, RYGB will need more careful post-transplant monitoring given the observed higher BPAR rate.

National Trends in Bariatric Surgery 2012-2015: Demographics, Procedure Selection, Readmissions, and Cost

BACKGROUND

Bariatric surgery is widely accepted as the best treatment for obesity and type 2 diabetes mellitus (T2DM). The Roux-en-Y gastric bypass (RYGB) and the sleeve gastrectomy (SG) have become the predominant bariatric procedures in the USA over the last several years, although the most recent trends in selection are unknown.

OBJECTIVE

The objective of this study is to assess selection trends, readmission rates, and cost of bariatric procedures in the USA from 2012 to 2015.

METHODS

We used the Premier database from 2012 to 2015 to examine trends in incidence of RYGB, adjustable gastric banding (LAGB), and SG; readmissions; and cost. Multivariate regression was performed to identify predictors of readmission.

RESULTS

The proportion of SG went up from 38 to 63% while the RYGB decreased from 44 to 30% over this time period. LAGB has decreased in use from 13 to 2%. In comparison to RYGB, readmission was less likely for SG (OR 0.64), males (OR 0.91), and more likely for black race (OR 1.27). The overall proportion of patients seeking RYGB with type 2 diabetes was higher than with SG (36 versus 25%), but SG has now overtaken RYGB as the most common procedure among diabetics. The SG is less costly than RYGB ($11,183 versus $13,485).

CONCLUSIONS

There is a continued overall trend in the increased popularity of the SG and decreased utilization of the RYGB and LAGB, although growth of the SG appears to be slowing. This is also true among patients with type 2 diabetes mellitus. Regardless of surgery type, underinsured and African-American race were more likely to be readmitted.

Obesity in Women: Insights for the Clinician

As a leading cause of morbidity and mortality in the United States and worldwide, obesity is a disease that is frequently encountered in clinical practice today and requires a range of medical interventions. While obesity affects both men and women across all ages, multiple issues are particularly germane to women's health, particularly as obesity is more prevalent among women than men in the United States and obesity among women of reproductive health relates to the growing issue of childhood obesity. Discussed herein are the epidemiology and pathophysiology of obesity along with the impact of perinatal obesity on fetal programming. Guidance on screening and management of obesity through lifestyle intervention, pharmacologic therapy, and bariatric surgery, as well as avoidance of weight-promoting medications wherever possible, is elaborated. Particular attention is paid to the contribution of these modalities to weight loss as well as their impact on obesity-related comorbidities that affect a woman's overall health, such as type 2 diabetes and hypertension, and her reproductive and gynecologic health. With modest weight loss, women with obesity can achieve notable improvements in chronic medical conditions, fertility, pregnancy outcomes, and symptoms of pelvic floor disorders. Moreover, as children born to women after bariatric surgery-induced weight loss show improved metabolic outcomes, this demonstrates a role for maternal weight loss in reducing risk of development of metabolic disturbances in children. In light of the immense cost burden and mortality from obesity, it is important to emphasize the role of lifestyle intervention, pharmacologic management, and bariatric surgery for weight loss in clinical practice to mitigate the impact of obesity on women's health.

Beta-cell sensitivity to glucose is impaired after gastric bypass surgery

AIMS

Patients who have undergone Roux-en-Y gastric bypass surgery (GB) have exaggerated postprandial insulin secretion, which has been attributed to increased meal glucose appearance and enhanced incretin effect. Here, we sought to determine β-cell glucose sensitivity in the absence of meal stimulation and insulinotropic gut factors.

MATERIALS AND METHODS

A total of 12 non-diabetic subjects with prior GB, and 7 matched non-surgical control subjects with normal glucose tolerance were studied. Blood glucose and insulin secretion rates were measured during a graded glucose infusion at increasing and then decreasing rates. Insulin sensitivity (S_I ) and glucose effectiveness (S_G ) were determined by the minimal model.

RESULTS

GB subjects had S_I comparable to that of control subjects. GB subjects had relative hyperglycaemia during the highest dose of glucose infusion associated with significantly reduced β-cell glucose sensitivity throughout both step-up (GB: 34 ± 6, CN: 82 ± 9 pmol min^-1 mM^-1 L, P < .0001) and step-down (GB: 31 ± 6, CN: 74 ± 9 pmol min^-1 mM^-1 L, P < .0001) phases of the glucose infusion. GB subjects also had reduced S_G (GB: 0.04 ± 0.00, CN: 0.07 ± 0.01 min^-1 , P = .004).

CONCLUSION

In the absence of enteric stimuli, β-cell sensitivity to changes in glycaemia is blunted among individuals with GB, indicating a significant shift in a fundamental property of β-cell function several years after surgery.

Clinical and Patient-Centered Outcomes in Obese Patients With Type 2 Diabetes 3 Years After Randomization to Roux-en-Y Gastric Bypass Surgery Versus Intensive Lifestyle Management: The SLIMM-T2D Study

OBJECTIVE

To compare the effect of Roux-en-Y gastric bypass (RYGB) surgery versus intensive medical diabetes and weight management (IMWM) on clinical and patient-reported outcomes in obese patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We prospectively randomized 38 obese patients with type 2 diabetes (15 male and 23 female, with mean ± SD weight 104 ± 16 kg, BMI 36.3 ± 3.4 kg/m², age 52 ± 6 years, and HbA_1c 8.5 ± 1.3% [69 ± 14 mmol/mol]) to laparoscopic RYGB (n = 19) or IMWM (n = 19). Changes in weight, HbA_1c, cardiovascular risk factors (UKPDS risk engine), and self-reported health status (the 36-Item Short-Form [SF-36] survey, Impact of Weight on Quality of Life [IWQOL] instrument, and Problem Areas in Diabetes Survey [PAID]) were assessed.

RESULTS

After 3 years, the RYGB group had greater weight loss (mean -24.9 kg [95% CI -29.5, -20.4] vs. -5.2 [-10.3, -0.2]; P < 0.001) and lowering of HbA_1c (-1.79% [-2.38, -1.20] vs. -0.39% [-1.06, 0.28] [-19.6 mmol/mol {95% CI -26.0, -13.1} vs. -4.3 {-11.6, 3.1}]; P < 0.001) compared with the IMWM group. Changes in cardiometabolic risk for coronary heart disease and stroke were all more favorable in RYGB versus IMWM (P < 0.05 to P < 0.01). IWQOL improved more after RYGB (P < 0.001), primarily due to subscales of physical function, self-esteem, and work performance. SF-36 and PAID scores improved in both groups, with no difference between treatments. A structural equation model demonstrated that improvement in overall quality of life was more strongly associated with weight loss than with improved HbA_1c and was manifest by greater improvements in IWQOL than with either SF-36 or PAID.

CONCLUSIONS

Three years after randomization to RYGB versus IMWM, surgery produced greater weight loss, lower HbA_1c, reduced cardiovascular risk, and improvements in obesity-related quality of life in obese patients with type 2 diabetes.

Effects of Weight-Loss Medications on Cardiometabolic Risk Profiles: A Systematic Review and Network Meta-analysis

BACKGROUND & AIMS

We performed a systematic review and network meta-analysis to evaluate the overall and comparative effects of weight-loss medications approved by the Food and Drug Administration for long-term use on cardiometabolic risk profiles of obese adults.

METHODS

We performed a systematic literature review through February 28, 2017 to identify randomized clinical trials of the effects of Food and Drug Administration-approved weight-loss medications (ie, orlistat, lorcaserin, naltrexone-bupropion, phentermine-topiramate, and liraglutide) administered to obese adults for 1 year or more, compared with placebo or another active agent. Outcomes of interest included changes in blood glucose (fasting blood glucose [FBG] and hemoglobin A1c), cholesterol profile (low-density lipoprotein and high-density lipoproteins), blood pressure (BP; systolic/diastolic), and waist circumference (WC). We performed pair-wise and network meta-analyses with outcomes reported as weighted and standardized mean differences. Quality of evidence was rated using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

In a meta-analysis of 28 randomized controlled trials (29,018 participants; median body mass index, 36.1 kg/m²), we associated weight-loss medications with a modest decrease in FBG (weighted mean difference, 4.0 mg/dL; 95% confidence interval, -4.4 to -3.6 mg/dL) and WC (weighted mean difference, reduction of 3.3 cm; 95% confidence interval, -3.5 to -3.1 cm), without clinically meaningful changes in systolic/diastolic BP or cholesterol profile vs placebo (standardized mean difference <0.2); effects varied among drugs. Phentermine-topiramate use was associated with a substantial decrease in WC and a modest decrease in FBG, hemoglobin A1c, and BP, and had minimal effect on cholesterol. Liraglutide use was associated with a substantial decrease in FBG, hemoglobin A1c, and WC, and a minimal effect on BP and cholesterol. Naltrexone-bupropion use was associated with moderate increase in high-density lipoprotein cholesterol, but had a minimal effect on FBG and WC. Orlistat use was associated with a decrease in low-density lipoprotein and high-density lipoprotein cholesterol. No drug improved all cardiometabolic risk factors.

CONCLUSIONS

In a systematic review and network meta-analysis, we found Food and Drug Administration-approved weight-loss medications to have only modest positive effects on cardiometabolic risk profile. Further research is needed to evaluate the long-term cardiometabolic benefits of these medications.

PROSPERO

CRD42016039486.

Cost-effectiveness analysis of bariatric surgery for morbid obesity in Belgium

AIMS

This study presents the cost-effectiveness analysis of bariatric surgery in Belgium from a third-party payer perspective for a lifetime and 10-year horizon.

MATERIALS AND METHODS

A decision analytic model incorporating Markov process was developed to compare the cost-effectiveness of gastric bypass, sleeve gastrectomy, and adjustable gastric banding against conventional medical management (CMM). In the model, patients could undergo surgery, or experience post-surgery complications, type 2 diabetes, cardiovascular diseases, or die. Transition probabilities, costs, and utilities were derived from the literature. The impact of different surgical methods on body mass index (BMI) level in the base-case analysis was informed by the Scandinavian Obesity Surgery Registry and the Swedish Obese Subject (SOS) study. Healthcare resource use and costs were obtained from Belgian sources. A base-case analysis was performed for the population, the characteristics of which were obtained from surgery candidates in Belgium.

RESULTS

In the base-case analysis over a 10-year time horizon, the increment in quality-adjusted life-years (QALYs) gained from bariatric surgery vs CMM was 1.4 per patient, whereas the incremental cost was €3,788, leading to an incremental cost-effectiveness ratio (ICER) of €2,809 per QALY. Over a lifetime, bariatric surgery produced savings of €9,332, an additional 1.1 life years and 5.0 QALYs. Bariatric surgery was cost-effective at 10 years post-surgery and dominant over conventional management over a lifetime horizon.

LIMITATIONS

The model did not include the whole scope of obesity-related complications, and also did not account for variation in surgery outcomes for different populations of diabetic patients. Also, the data about management of patients after surgery was based on assumptions and the opinion of a clinical expert.

CONCLUSIONS

It was demonstrated that a current mix of bariatric surgery methods was cost-effective at 10 years post-surgery and cost-saving over the lifetime of the Belgian patient cohort considered in this analysis.

Prevalence and predictors of postoperative thiamine deficiency after vertical sleeve gastrectomy

BACKGROUND

As the vertical sleeve gastrectomy (VSG) becomes increasingly popular, its effect on postoperative micronutrient levels, such as thiamine, becomes more important. We previously found a 1.8% prevalence of thiamine deficiency in bariatric patients before surgery.

OBJECTIVE

The aims of this study were to determine the prevalence of thiamine deficiency at our center after VSG and to explore possible predictors of postoperative thiamine levels.

SETTING

University hospital, United States.

METHODS

A retrospective chart review was performed on 147 bariatric patients between 18- and 65-years old who underwent VSG between April 2011 and February 2015. Demographic characteristics, preoperative body mass index (BMI), obesity-associated co-morbidities, alcohol intake, smoking habits, insurance type, calendar year of the procedure, occurrence of postoperative complications, and compliance with postoperative nutrition and follow-up appointment guidelines were extracted from clinical charts. We defined thiamine deficiency as<78 nM on any lab draw within 1 year after the VSG. The χ², Fisher exact, and Mann-Whitney U tests, and multivariate logistic regression models were created to analyze the association of the above factors with thiamine deficiency after a VSG.

RESULTS

Of 147 patients, 105 met inclusion criteria and were analyzed, of whom 27 (25.7%) had thiamine deficiency. Overall median age was 42 years (interquartile ratio: 36, 49). The majority of patients were either African Americans or Caucasian (47.6% and 44.8%, respectively), female (77.1%), and compliant with vitamins (81.0%). The overall mean preoperative BMI was 46.4 kg/m². Patients with thiamine deficiency were more likely to be African American (66.7%, P = .024), have a larger preoperative BMI (P = .026), and to report repetitive episodes of nausea (59.3%, P = .002) and vomiting (44.4%, P = .001) at any of their postoperative appointments within 1 year after surgery. Compliance with vitamins did not differ between those with or without thiamine deficiency (70.4%, 84.6%, P = .10). After controlling for all factors, African American race (odds ratio [OR] 3.9, P = .019), higher preoperative BMI (OR 1.13, P = .001), nausea (OR 3.81, P = .02), and vomiting (OR 3.49, P = .032) were independent risk factors for the development of thiamine deficiency.

CONCLUSIONS

We found an alarmingly high prevalence of thiamine deficiency in postoperative SG patients. This disorder may have serious consequences including Wernicke encephalopathy; hence, it is important to identify predictive demographic, postoperative, and behavioral factors so that appropriate measures can be taken to prevent thiamine deficiency in VSG patients.

Surgical Treatment of Obesity in Latinos and African Americans: Future Directions and Recommendations to Reduce Disparities in Bariatric Surgery

Introduction: Obesity and metabolic syndrome are increasingly prevalent in the United States, particularly among African Americans and Latinos. Bariatric surgery has become one of the primary treatment modalities for obesity and type 2 diabetes. However, fewer Latinos and African Americans are undergoing bariatric surgery than whites. The aim of this article is to describe the disparities in seeking and accessing bariatric surgery, describe the outcomes following bariatric procedures in Latinos and African Americans, and offer recommendations and future research directions that may assist in addressing these disparities. Methods: Original research and review articles published in English were reviewed. Results: Potential reasons why Latinos and African Americans have low rates of seeking bariatric surgery are described. Disparities in access to care and financial coverage, low rates of referral by primary care providers, and cultural attitudes toward obesity in conjunction with mistrust of the healthcare system are discussed as potential contributors to the low rate of bariatric surgery in Latinos and African Americans. Finally, disparities in bariatric surgery outcomes, comorbidities, and complications are reviewed. Conclusions: Additional research studies in bariatric surgical disparities are needed. Recommendations and future directions that may help to reduce disparities in bariatric surgery are discussed.

Meta-analysis of bariatric surgery versus non-surgical treatment for type 2 diabetes mellitus

Background

To compare short-term and long-term results of bariatric surgery vs non-surgical treatment for type 2 diabetes mellitus (T2DM).

Methods

A systematic search was conducted in the PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs). All statistical analysis was performed using Review Manager version 5.3. The dichotomous data was calculated using risk ratio (RR) and continuous data was using mean differences (MD) along with 95% confidence intervals (CI).

Results

A total of 8 RCTs with 619 T2DM patients were analyzed. Compared with non-surgical treatment group, bariatric surgery group was associated with higher rate T2DM remission (RR = 5.76, 95%CI:3.15-10.55, P < 0.00001), more reduction HbA_1C (MD = 1.29, 95%CI: -1.70 to -0.87, P < 0.00001), more decrease fasting plasma glucose (MD = -36.38, 95%CI: -51.76 to -21.01, P < 0.00001), greater loss body weight (MD = -16.93, 95%CI: 19.78 to -14.08, P < 0.00001), more reduction body mass index (MD = -5.80, 95%CI: -6.95 to -4.64, P < 0.00001), more decrease triglyceride concentrations (MD = -51.27, 95%CI: -74.13 to -28.41, P < 0.0001), and higher increase density lipoprotein cholesterol (MD = 9.10, 95%CI: 7.99 to 10.21; P < 0.00001). But total and low density lipoprotein cholesterol were no significant changes.

Conclusion

Bariatric surgery for T2DM is efficacious and improves short- and long-term outcomes as compared with non-surgical treatment.

Gastric Bypass-Related Effects on Glucose Control, β Cell Function and Morphology in the Obese Zucker Rat

BACKGROUND

Roux-en-Y gastric bypass (RYGB) may improve beta cell function by mechanisms other than caloric restriction and body weight loss. We aimed to assess the impact of anatomical and hormonal alterations specific to RYGB on glucose homeostasis, β cell function and morphology.

METHODS

Male Zucker(fa/fa) rats underwent either RYGB (n = 11) or sham surgeries (n = 10). Five of the shams were then food restricted and body weight matched (BWM) to the RYGB rats. Six male Zucker(fa/+) rats underwent sham surgery and served as additional lean controls. Twenty-seven days after surgery, an oral glucose tolerance test (OGTT) was performed and plasma levels of glucose, insulin and glucagon-like peptide-1 (GLP-1) were measured. Immunohistological analysis of pancreatic islets was performed, and GLP-1 receptor and PDX-1 mRNA content were quantified.

RESULTS

Shams consumed more food and gained more weight compared to both RYGB and BWM (p < 0.001). Hyperglycaemia was evident in ad libitum-fed shams, whilst postprandial glucose levels were lower in RYGB compared to the BWM sham group (p < 0.05). During the OGTT, RYGB rats responded with >2.5-fold increase of GLP-1. Histology revealed signs of islet degeneration in ad libitum-fed shams, but not in RYGB and sham BWM controls (p < 0.001). GLP-1 receptor and PDX-1 mRNA content was similar between the RYGB and BWM shams but higher compared to ad libitum shams (p < 0.05).

CONCLUSIONS

Combined molecular, cellular and histological analyses of pancreatic function suggest that weight loss alone, and not the enhancement of GLP-1 responses, is predominant for the short-term β cell protective effects of RYGB.

Partitioning of adipose lipid metabolism by altered expression and function of PPAR isoforms after bariatric surgery

BACKGROUND

Bariatric surgery remains the most effective treatment for reducing adiposity and eliminating type 2 diabetes; however, the mechanism(s) responsible have remained elusive. Peroxisome proliferator-activated receptors (PPAR) encompass a family of nuclear hormone receptors that upon activation exert control of lipid metabolism, glucose regulation and inflammation. Their role in adipose tissue following bariatric surgery remains undefined.

MATERIALS AND METHODS

Subcutaneous adipose tissue biopsies and serum were obtained and evaluated from time of surgery and on postoperative day 7 in patients randomized to Roux-en-Y gastric bypass (n=13) or matched caloric restriction (n=14), as well as patients undergoing vertical sleeve gastrectomy (n=33). Fat samples were evaluated for changes in gene expression, protein levels, β-oxidation, lipolysis and cysteine oxidation.

RESULTS

Within 7 days, bariatric surgery acutely drives a change in the activity and expression of PPARγ and PPARδ in subcutaneous adipose tissue thereby attenuating lipid storage, increasing lipolysis and potentiating lipid oxidation. This unique metabolic alteration leads to changes in downstream PPARγ/δ targets including decreased expression of fatty acid binding protein (FABP) 4 and stearoyl-CoA desaturase-1 (SCD1) with increased expression of carnitine palmitoyl transferase 1 (CPT1) and uncoupling protein 2 (UCP2). Increased expression of UCP2 not only facilitated fatty acid oxidation (increased 15-fold following surgery) but also regulated the subcutaneous adipose tissue redoxome by attenuating protein cysteine oxidation and reducing oxidative stress. The expression of UCP1, a mitochondrial protein responsible for the regulation of fatty acid oxidation and thermogenesis in beige and brown fat, was unaltered following surgery.

CONCLUSIONS

These results suggest that bariatric surgery initiates a novel metabolic shift in subcutaneous adipose tissue to oxidize fatty acids independently from the beiging process through regulation of PPAR isoforms. Further studies are required to understand the contribution of this shift in expression of PPAR isoforms to weight loss following bariatric surgery.

Prediction of type 2 diabetes remission after metabolic surgery: a comparison of the individualized metabolic surgery score and the ABCD score

BACKGROUND

Metabolic surgery has become increasingly accepted for the treatment of type 2 diabetes (T2D). However, there is limited evidence regarding the optimal candidate and surgical procedure. Although a new individualized metabolic surgery (IMS) score was recently proposed for procedure selection, it has yet to be validated.

OBJECTIVE

To validate the IMS score with regard to remission of T2D after metabolic surgery and compare it with the age, body mass index, C-peptide level, and duration of T2D (ABCD) score.

SETTING

Hospital-based bariatric center.

METHODS

A total of 310 T2D patients who underwent gastric bypass and sleeve gastrectomy at an academic center in Taiwan and had a minimum 5-year follow-up (2004-2012) were examined for the predictive power of complete remission using the IMS and the ABCD scoring systems.

RESULTS

At the 5-year follow-up, weight loss was 27.5%, with mean body mass index decreasing from 37.8 to 27.9 kg/m², mean glycated hemoglobin decreased from 8.6% to 6.1%, and prolonged remission of T2D achieved in 224 (72.3%) T2D patients. Remission rates were higher in patients who underwent gastric bypass than in those who underwent sleeve gastrectomy (73.6% versus 66.1%; P = .04), regardless of T2D severity, and were 96%, 68%, and 16% in patients with IMS mild, moderate, and severe scores, respectively. Although both scores predicted the success of surgery, the ABCD was better in patients with IMS moderate scores.

CONCLUSION

Metabolic surgery is an option for T2D patients with obesity. The ABCD score may be better at predicting T2D remission after metabolic surgery compared with the IMS score.

Association of Bariatric Surgery vs Medical Obesity Treatment With Long-term Medical Complications and Obesity-Related Comorbidities

IMPORTANCE

The association of bariatric surgery and specialized medical obesity treatment with beneficial and detrimental outcomes remains uncertain.

OBJECTIVE

To compare changes in obesity-related comorbidities in patients with severe obesity (body mass index ≥40 or ≥35 and at least 1 comorbidity) undergoing bariatric surgery or specialized medical treatment.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study with baseline data of exposures from November 2005 through July 2010 and follow-up data from 2006 until death or through December 2015 at a tertiary care outpatient center, Vestfold Hospital Trust, Norway. Consecutive treatment-seeking adult patients (n = 2109) with severe obesity assessed (221 patients excluded and 1888 patients included).

EXPOSURES

Bariatric surgery (n = 932, 92% gastric bypass) or specialized medical treatment (n = 956) including individual or group-based lifestyle intervention programs.

MAIN OUTCOMES AND MEASURES

Primary outcomes included remission and new onset of hypertension based on drugs dispensed according to the Norwegian Prescription Database. Prespecified secondary outcomes included changes in comorbidities. Adverse events included complications retrieved from the Norwegian Patient Registry and a local laboratory database.

RESULTS

Among 1888 patients included in the study, the mean (SD) age was 43.5 (12.3) years (1249 women [66%]; mean [SD] baseline BMI, 44.2 [6.1]; 100% completed follow-up at a median of 6.5 years [range, 0.2-10.1]). Surgically treated patients had a greater likelihood of remission and lesser likelihood for new onset of hypertension (remission: absolute risk [AR], 31.9% vs 12.4%); risk difference [RD], 19.5% [95% CI, 15.8%-23.2%], relative risk [RR], 2.1 [95% CI, 2.0-2.2]; new onset: AR, 3.5% vs 12.2%, RD, 8.7% [95% CI, 6.7%-10.7%], RR, 0.4 [95% CI, 0.3-0.5]; greater likelihood of diabetes remission: AR, 57.5% vs 14.8%; RD, 42.7% [95% CI, 35.8%-49.7%], RR, 3.9 [95% CI, 2.8-5.4]; greater risk of new-onset depression: AR, 8.9% vs 6.5%; RD, 2.4% [95% CI, 1.3%-3.5%], RR, 1.5 [95% CI, 1.4-1.7]; and treatment with opioids: AR, 19.4% vs 15.8%, RD, 3.6% [95% CI, 2.3%-4.9%], RR, 1.3 [95% CI, 1.2-1.4]). Surgical patients had a greater risk for undergoing at least 1 additional gastrointestinal surgical procedure (AR, 31.3% vs 15.5%; RD, 15.8% [95% CI, 13.1%-18.5%]; RR, 2.0 [95% CI, 1.7-2.4]). The proportion of patients with low ferritin levels was significantly greater in the surgical group (26% vs 12%, P < .001).

CONCLUSIONS AND RELEVANCE

Among patients with severe obesity followed up for a median of 6.5 years, bariatric surgery compared with medical treatment was associated with a clinically important increased risk for complications, as well as lower risks of obesity-related comorbidities. The risk for complications should be considered in the decision-making process.

Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss at 5 Years Among Patients With Morbid Obesity: The SLEEVEPASS Randomized Clinical Trial

Importance

Laparoscopic sleeve gastrectomy for treatment of morbid obesity has increased substantially despite the lack of long-term results compared with laparoscopic Roux-en-Y gastric bypass.

Objective

To determine whether laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass are equivalent for weight loss at 5 years in patients with morbid obesity.

Design, Setting, and Participants

The Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial was conducted from March 2008 until June 2010 in Finland. The trial enrolled 240 morbidly obese patients aged 18 to 60 years, who were randomly assigned to sleeve gastrectomy or gastric bypass with a 5-year follow-up period (last follow-up, October 14, 2015).

Interventions

Laparoscopic sleeve gastrectomy (n = 121) or laparoscopic Roux-en-Y gastric bypass (n = 119).

Main Outcomes and Measures

The primary end point was weight loss evaluated by percentage excess weight loss. Prespecified equivalence margins for the clinical significance of weight loss differences between gastric bypass and sleeve gastrectomy were -9% to +9% excess weight loss. Secondary end points included resolution of comorbidities, improvement of quality of life (QOL), all adverse events (overall morbidity), and mortality.

Results

Among 240 patients randomized (mean age, 48 [SD, 9] years; mean baseline body mass index, 45.9, [SD, 6.0]; 69.6% women), 80.4% completed the 5-year follow-up. At baseline, 42.1% had type 2 diabetes, 34.6% dyslipidemia, and 70.8% hypertension. The estimated mean percentage excess weight loss at 5 years was 49% (95% CI, 45%-52%) after sleeve gastrectomy and 57% (95% CI, 53%-61%) after gastric bypass (difference, 8.2 percentage units [95% CI, 3.2%-13.2%], higher in the gastric bypass group) and did not meet criteria for equivalence. Complete or partial remission of type 2 diabetes was seen in 37% (n = 15/41) after sleeve gastrectomy and in 45% (n = 18/40) after gastric bypass (P > .99). Medication for dyslipidemia was discontinued in 47% (n = 14/30) after sleeve gastrectomy and 60% (n = 24/40) after gastric bypass (P = .15) and for hypertension in 29% (n = 20/68) and 51% (n = 37/73) (P = .02), respectively. There was no statistically significant difference in QOL between groups (P = .85) and no treatment-related mortality. At 5 years the overall morbidity rate was 19% (n = 23) for sleeve gastrectomy and 26% (n = 31) for gastric bypass (P = .19).

Conclusions and Relevance

Among patients with morbid obesity, use of laparoscopic sleeve gastrectomy compared with use of laparoscopic Roux-en-Y gastric bypass did not meet criteria for equivalence in terms of percentage excess weight loss at 5 years. Although gastric bypass compared with sleeve gastrectomy was associated with greater percentage excess weight loss at 5 years, the difference was not statistically significant, based on the prespecified equivalence margins.

Trial Registration

clinicaltrials.gov Identifier: NCT00793143.

Lifestyle Intervention and Medical Management With vs Without Roux-en-Y Gastric Bypass and Control of Hemoglobin A1c, LDL Cholesterol, and Systolic Blood Pressure at 5 Years in the Diabetes Surgery Study

IMPORTANCE

The Roux-en-Y gastric bypass is effective in achieving established diabetes treatment targets, but durability is unknown.

OBJECTIVE

To compare durability of Roux-en-Y gastric bypass added to intensive lifestyle and medical management in achieving diabetes control targets.

DESIGN, SETTING, AND PARTICIPANTS

Observational follow-up of a randomized clinical trial at 4 sites in the United States and Taiwan, involving 120 participants who had a hemoglobin A1c (HbA1c) level of 8.0% or higher and a body mass index between 30.0 and 39.9 (enrolled between April 2008 and December 2011) were followed up for 5 years, ending in November 2016.

INTERVENTIONS

Lifestyle-intensive medical management intervention based on the Diabetes Prevention Program and LookAHEAD trials for 2 years, with and without (60 participants each) Roux-en-Y gastric bypass surgery followed by observation to year 5.

MAIN OUTCOMES AND MEASURES

The American Diabetes Association composite triple end point of hemoglobin A1c less than 7.0%, low-density lipoprotein cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg at 5 years.

RESULTS

Of 120 participants who were initially randomized (mean age, 49 years [SD, 8 years], 72 women [60%]), 98 (82%) completed 5 years of follow-up. Baseline characteristics were similar between groups: mean (SD) body mass index 34.4 (3.2) for the lifestyle-medical management group and 34.9 (3.0) for the gastric bypass group and had hemoglobin A1c levels of 9.6% (1.2) and 9.6% (1.0), respectively. At 5 years, 13 participants (23%) in the gastric bypass group and 2 (4%) in the lifestyle-intensive medical management group had achieved the composite triple end point (difference, 19%; 95% CI, 4%-34%; P = .01). In the fifth year, 31 patients (55%) in the gastric bypass group vs 8 (14%) in the lifestyle-medical management group achieved an HbA1c level of less than 7.0% (difference, 41%; 95% CI, 19%-63%; P = .002). Gastric bypass had more serious adverse events than did the lifestyle-medical management intervention, 66 events vs 38 events, most frequently gastrointestinal events and surgical complications such as strictures, small bowel obstructions, and leaks. Gastric bypass had more parathyroid hormone elevation but no difference in B12 deficiency.

CONCLUSIONS AND RELEVANCE

In extended follow-up of obese adults with type 2 diabetes randomized to adding gastric bypass compared with lifestyle and intensive medical management alone, there remained a significantly better composite triple end point in the surgical group at 5 years. However, because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00641251.

The comprehensive summary of surgical versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomized controlled trials

Background

Bariatric surgery has emerged as a competitive strategy for obese patients. However, its comparative efficacy against non-surgical treatments remains ill-defined, especially among nonseverely obese crowds. Therefore, we implemented a systematic review and meta-analysis in order for an academic addition to current literatures.

Methods

Literatures were retrieved from databases of PubMed, Web of Science, EMBASE and Cochrane Library. Randomized trials comparing surgical with non-surgical therapies for obesity were included. A Revised Jadad's Scale and Risk of Bias Summary were employed for methodological assessment. Subgroups analysis, sensitivity analysis and publication bias assessment were respectively performed in order to find out the source of heterogeneity, detect the outcome stability and potential publication bias.

Results

25 randomized trials were eligibly included, totally comprising of 1194 participants. Both groups displayed well comparability concerning baseline parameters (P > 0.05). The pooled results of primary endpoints (weight loss and diabetic remission) revealed a significant advantage among surgical patients rather than those receiving non-surgical treatments (P < 0.05). Furthermore, except for certain cardiovascular indicators, bariatric surgery was superior to conventional arms in terms of metabolic secondary parameters (P < 0.05). Additionally, the pooled outcomes were confirmed to be stable by sensitivity analysis. Although Egger's test (P < 0.01) and Begg's test (P<0.05) had reported the presence of publication bias among included studies, “Trim-and-Fill” method verified that the pooled outcomes remained stable.

Conclusion

Bariatric surgery is a better therapeutic option for weight loss, irrespective of follow-up duration, surgical techniques and obesity levels.

Milestone Weight Loss Goals (Weight Normalization and Remission of Obesity) after Gastric Bypass Surgery: Long-Term Results from the University of Michigan

BACKGROUND

Rates of weight normalization and obesity remission after Roux-en-Y gastric bypass (GB) are unknown. This study evaluated weight loss, rates of achieving body mass index (BMI) <25 or 30 kg/m², recidivism, and predictors of success following GB.

METHODS

We retrospectively studied weight and BMI at baseline, 2 and 6 months, and annually at 1-7 years in 219 patients undergoing GB at the University of Michigan from January 2008 to November 2010.

RESULTS

Follow-up was excellent for a population traditionally associated with high attrition rates with data availability of 157/219, 145/219, 144/219, 134/219, 123/219, 82/161, and 29/64 patients at 1-7 years, respectively. Mean baseline BMI was 47.0 kg/m². Weight normalization (BMI <25 kg/m²) occurred in 2.3-6.8% of patients. More importantly, 47% of patients achieved remission of obesity (BMI <30 kg/m²) at some time point and 24% (52/219) at the last observed time point. BMI <30 kg/m² was associated with a lower initial BMI and follow-up for more than 2 years.

CONCLUSIONS

Rates of weight normalization are low after GB; however, a large number of patients achieved BMI <30 kg/m². While the percent total weight loss and excess weight loss are both quite high in the entire cohort and this is likely associated with significant health benefits, our results still underscore the need to address obesity with intensive clinical attention earlier in its course.

Long-Term Outcomes of Three Types of Bariatric Surgery on Obesity and Type 2 Diabetes Control and Remission

BACKGROUND

Different bariatric surgeries have demonstrated different effectiveness for weight loss and glucose control in obese persons with diabetes, over a short follow-up time. The aim of this study was to compare weight loss, glucose control, and diabetes remission in individuals with type 2 diabetes, after three types of bariatric surgery: gastric banding (GB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB), with 5 years follow-up.

METHODS

A retrospective study was conducted on bariatric surgeries performed during 2002-2011 in a large nationwide healthcare organization.

RESULTS

Of 2190 patients, 64.8 % were women. The operations performed were 1027 GB, 1023 SG, and 140 RYGB. Mean BMI ± SD at baseline, 1 year postoperatively, and 5 years postoperatively were 43.5 ± 6.18, 37.1 ± 6.35, and 35.5 ± 6.48 for GB; 43.6 ± 6.42, 34.4 ± 6.08, and 35.3 ± 6.7 for SG; and 42.8 ± 5.81, 32.8 ± 4.9, and 34.1 ± 5.09 for RYGB. Mean HbA1c ± SD at baseline, 1 year postoperatively, and 5 years postoperatively were 7.6 + 1.58, 6.5 + 1.22, and 6.8 + 1.48 for GB; 7.7 + 1.63, 6.4 + 1.18, and 6.7 + 1.57 for SG; and 8.0 + 1.78, 6.3 + 0.98, and 7.04 + 1.42 for RYGB. At 1 year follow-up, 53.2 % had achieved remission; at 5 years, 54.4 %. Remission rates at 5 years were similar for the three surgeries. Five-year remission was inversely associated with baseline HbA1c and with treatment with insulin at baseline and positively associated with BMI.

CONCLUSIONS

For all three surgeries, diabetes remission was higher than the baseline after 5 years; mean BMI and HbA1c decreased considerably during the first year postoperatively and remained lower than basal values throughout follow-up. Early improvements were greatest for RYGB, though the advantage over the other operations diminished with time.

Obesity: Pathophysiology and Management

Obesity continues to be among the top health concerns across the globe. Despite our failure to contain the high prevalence of obesity, we now have a better understanding of its pathophysiology, and how excess adiposity leads to type 2 diabetes, hypertension, and cardiovascular disease. Lifestyle modification is recommended as the cornerstone of obesity management, but many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. Fortunately, 5 drug therapies-orlistat, lorcaserin, liraglutide, phentermine/topiramate, and naltrexone/bupropion-are available for long-term weight management. Additionally, several medical devices are available for short-term and long-term use. Bariatric surgery yields substantial and sustained weight loss with resolution of type 2 diabetes, although due to the high cost and a small risk of serious complications, it is generally recommended for patients with severe obesity. Benefit-to-risk balance should guide treatment decisions.

Bariatric Surgery for Obesity

In this review, the authors discuss the indications for and the published outcomes of commonly performed bariatric procedures, including weight loss, perioperative morbidity and mortality, late complications, as well as the impact of bariatric surgery on comorbidities, cardiovascular risk, and mortality. They also briefly discuss the mechanisms by which bariatric/metabolic surgery causes such significant weight loss and health gain.

Metabolic Effects of Bariatric Surgery

BACKGROUND

Obesity can be defined as a chronic subcortical brain disease, as there is an important neurophysiological component to its etiology based on changes in the functioning of those areas of the brain controlling food intake and reward. Extensive metabolic changes accompany bariatric surgery-based treatment of obesity. Consequently, the term “metabolic” surgery is being increasingly adopted in relation to the beneficial effects these procedures have on chronic diseases like type 2 diabetes.

CONTENT

In the present review, we focus on the key biochemical and physiological changes induced by metabolic surgery and highlight the beneficial effects accrued systemically with the use of an organ-based approach. Understanding the impact on and interactions between the gut, brain, adipose tissue, liver, muscle, pancreas, and kidney is key to understanding the sum of the metabolic effects of these operations.

SUMMARY

Further mechanistic studies are essential to assess the true potential of metabolic surgery to treat metabolic comorbidities of obesity beyond type 2 diabetes. Approaches that may mitigate the metabolic side effects of surgery also require attention. Understanding the positive impact of metabolic surgery on metabolic health may result in a wider acceptance of this intervention as treatment for metabolic, comorbid conditions.

National Differences in Remission of Type 2 Diabetes Mellitus After Roux-en-Y Gastric Bypass Surgery-Subgroup Analysis of 2-Year Results of the Diabetes Surgery Study Comparing Taiwanese with Americans with Mild Obesity (BMI 30-35 kg/m2)

Background

The purpose of this study is to compare effects of different nations on Roux-en-Y gastric bypass (RYGB) vs. intensive medical management (IMM) in achieving remission of type 2 diabetes mellitus (T2DM).

Materials and Methods

Between April 2008 and December 2011, this randomized, controlled clinical trial was conducted at four teaching hospitals in the United States and Taiwan involving 71 participants with mild obesity (BMI 30–35 kg/m²). Thirty-six of 71 participants were randomly assigned to the RYGB group, and the others were in IMM group. Partial or complete remission of T2DM was defined as blood HbA1c < 6.5 % (48 mmol/mol) or <6 % (42 mmol/mol) without any antihyperglycemic medication for at least 1-year duration, respectively.

Results

At baseline, Taiwanese participants had a lower BMI, younger age, and shorter duration of T2DM than American participants. At 24 months, weight loss was greater in the RYGB group in both populations than in the IMM group. No IMM participant of either population had partial or complete remission of T2DM. In the RYGB group, a substantial proportion of the subjects achieved complete or partial remission (57 % in Taiwanese and 27 % in American participants, P = 0.08). Logistic regression revealed stimulated C-peptide (Odds ratio 2.22, P = 0.02) but not nationality as a significant predictor of diabetes remission.

Conclusion

Adding RYGB to lifestyle and medical management was associated with a greater likelihood of remission of T2DM in both Taiwanese and American subjects with mild obesity with type 2 diabetes. Residual beta-cell function at baseline appears to be the major factor predicting remission of T2DM.

Trial registry number: clinicaltrials.gov Identifier: NCT00641251

Nutrient Deficiency 10 Years Following Roux-en-Y Gastric Bypass: Who's Responsible?

OBJECTIVE(S)

Monitoring and prevention of long-term nutrient deficiency after laparoscopic Roux-en-Y gastric bypass (LRYGB) remains ill defined due to limited surgical follow-up after bariatric surgery. This study compared nutrient supplementation as well as surgeon and primary care physician (PCP) follow-up between patients with short-term versus long-term follow-up.

METHODS

All patients undergoing LRYGB at a single institution in 2004 (long-term group, n = 281) and 2012-2013 (short-term group, n = 149) were evaluated. Prospectively collected database, electronic medical record (EMR) review and telephone survey were used to obtained follow-up for both cohorts. Multivariate logistic regression was used to assess factors independently predicting multivitamin use.

RESULTS

Complete follow-up was achieved in 172 (61 %) long-term and 107 (72 %) short-term patients. We demonstrate a significant difference (p < 0.0001) in time since last surgeon follow-up (13.3 ± 7.8 vs 86.9 ± 39.9 months) for the long-term group with no difference in PCP follow-up, (3.1 ± 4.3 vs 3.7 ± 3.4). Nutrient supplementation was higher in the short-term group, including multivitamin (70.3 vs 58.9 %, p < 0.05), iron (84.2 vs 67.1 %, p = 0.02), and calcium (49.5 vs 32.9 %, p = 0.01). After adjusting for interval since surgery, %EBMI and current comorbidities logistic regression (c = 0.797) demonstrated shorter time since last surgeon visit was independently predictive of multivitamin use (p = 0.001).

CONCLUSIONS

While it appears patients prefer to follow-up with their PCP, this study reveals a large disparity in malnutrition screening and nutrient supplementation following LRYGB. Therefore, implementation of multidisciplinary, best-practice guidelines to recognize and prevent malnutrition is paramount in the management of this growing population of high-risk patients.

[Quality indicators for metabolic and bariatric surgery in Germany : Evidence-based development of an indicator panel for the quality of results, indications and structure]

An expert committee was appointed by the German Society for General and Visceral Surgery to develop a panel of appropriate quality indicators to collate the quality of results, indications and structure in metabolic and bariatric surgery. This entailed assimilating the available evidence (systematic literature search), results from the national registry of the society (StuDoQ|MBE) and specific socioeconomic aspects (e. g. severely limited access to metabolic and bariatric surgery in Germany). These quality parameters were to be incorporated into the national guidelines and the rules of procedure for certification in the future. The committee concluded that mortality, MTL30 and severe complications needing intervention (Clavien-Dindo ≥ 3b) are suitable indicators to measure surgical outcome quality due to their relevance, scientific soundness and practicability. As a systematic follow-up is mandatory after bariatric surgery, a minimum follow-up quota is now required using reported quality of life data as an indicator of process quality. As intestinal bypass procedures have been shown to be superior in the treatment of type 2 diabetes, these procedures should be offered to eligible patients and also be performed. The proposed threshold values based on the results of the available literature and StuDoQ registry are to be considered as preliminary and need to be validated and adjusted if necessary in the future. The StuDoQ|MBE is considered a valuable tool to gather this information and also represents the appropriate infrastructure for the collation of relevant risk adjustors.

Bariatric surgery versus conservative management for morbidly obese patients in Spain: a cost-effectiveness analysis

BACKGROUND

We assessed the cost-effectiveness of bariatric surgery (BS) versus conservative management (CM) for treating morbid obesity in Spain.

METHODS

We developed a probabilistic Markov model to estimate health outcomes, quality-adjusted life years (QALY), life years gained (LYG), and costs over lifetime and 10-year horizons. Combined common BS procedures were compared with CM. Clinical and utility inputs were obtained from the literature and resource use and costs from local sources (€2017).

RESULTS

Over the 10-year horizon, BS led to a cost increment of €9,386 and 1.6 additional QALY (€5,966/QALY). Leading to 0.6 LYG and 4.4 QALY gains and €300/patient average cost savings over lifetime, BS could potentially significantly reduce diabetes and cardiovascular disease risk over the considered horizons. Despite short-term cost reductions, surgery delay may lead to significant clinical benefits loss.

CONCLUSIONS

Compared to CM, BS is a more effective and less costly alternative for treating morbid obesity in Spain.

Comparison of gaze behaviour of trainee and experienced surgeons during laparoscopic gastric bypass

Background

Eye tracking presents a novel tool that could be used to profile skill levels in surgery objectively. The primary aim of this study was to identify differences in gaze behaviour between expert and junior surgeons performing a laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity.

Methods

This prospective observational study used a lightweight eye-tracking apparatus to determine the difference in gaze behaviours between expert (more than 75 procedures) and junior (75 or fewer procedures) surgeons at defined stages of LRYGB. Primary endpoints were normalized dwell time and fixation frequency. Secondary endpoints were blink rate, maximum pupil size and rate of pupil change.

Results

A total of 20 procedures (12 junior, 8 expert) were analysed. Compared with juniors, experts showed a prolonged dwell time on the screen during angle of His dissection (median (range) 91·20 (83·40–94·40) versus 68·95 (59·80–87·60) per cent; P = 0·001), formation of the retrogastric tunnel (91·50 (85·80–95·50) versus 73·60 (34·60–90·50) per cent; P = 0·001) and gastric pouch formation (86·95 (83·60–90·20) versus 67·60 (37·10–80·00) per cent P &lt; 0·001). Juniors had a greater blink frequency throughout all recorded segments (P &lt; 0·010) and had a larger maximum pupil size during all recorded operative segments (P &lt; 0·010). Rate of pupil change was greater in juniors in all analysed segments (P &lt; 0·010).

Conclusion

These results suggest that experts display more focused attention on significant stimuli, alongside experiencing a reduced mental workload and having increased concentration. This has the potential for future use in validation of surgical skill in high-stakes assessment.

Mid-Term Remission of Type 2 Diabetes Mellitus After Laparoscopic Roux En-Y Gastric Bypass

BACKGROUND

Laparoscopic Roux en-Y gastric bypass (LRYGB) is an established therapeutic modality for type 2 diabetes mellitus (T2DM). However, there is paucity of data on the outcomes of LRYGB on T2DM beyond 2 years. This study aimed to examine the medium-term effects of LRYGB on T2DM and determine the predictors of T2DM resolution.

METHODS

Prospective data were collected for all consecutive LRYGB performed from September 2009 to November 2010. The American Diabetes Association guidelines were used to define complete (CR) or partial (PR) remission of diabetes. Diabetes status was considered improved when there was >50 % reduction in the dose of medications or when glycaemic control was achieved after stopping insulin. The effects of baseline characteristics, diabetes data and weight loss data at 4 years on T2DM remission were studied.

RESULTS

Forty-six patients with T2DM underwent LRYGB with mean ± SD age and body mass index (BMI) of 48.6 ± 9.6 years and 50.4 ± 6.5 kg/m², respectively. Median (IQR, interquartile range) duration of T2DM preoperatively was 60 (36-126) months. Median (IQR) follow-up was 52 (50-57) months. T2DM remission was achieved in 64 % of patients (44 % CR, 20 % PR), and a further 28 % of patients had improvement in their diabetes status. Multivariate analyses demonstrated significant excess weight loss (EWL) [P = 0.008] and lower BMI [P = 0.04] at 4 years to be the only independent predictors of T2DM medium-term outcomes.

CONCLUSION

The medium-term effects of LRYGB on T2DM remission/improvement were maintained in 92 % of patients. EWL and lower BMI at 4 years were independent predictors of T2DM remission.