Impact of roux-en Y gastric bypass surgery on prognostic factors of type 2 diabetes mellitus: meta-analysis and systematic review

Revision/Conversion Surgeries After One Anastomosis Gastric Bypass-An Experts' Modified Delphi Consensus

PURPOSE

There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method.

METHODS

Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus.

RESULTS

A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB.

CONCLUSION

While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.

Remission as an Emerging Therapeutic Target in Type 2 Diabetes in the Era of New Glucose-Lowering Agents: Benefits, Challenges, and Treatment Approaches

Type 2 diabetes mellitus (T2DM) is a progressive disease with a growing prevalence, associated with an increased risk of complications. The introduction of new classes of antidiabetic drugs into clinical practice has dramatically changed the landscape of diabetes therapy. However, despite the progress made in the pharmacotherapy of T2DM, mitigating the burden of the disease on individuals, societies and health care systems remains a challenge. Remission has recently emerged as a therapeutic target in T2DM, achievable through a wide range of interventions. Recent studies have shown that extensive lifestyle changes, such as weight reduction, bariatric surgery, and intensive glucose lowering therapy, can prompt the remission of diabetes, but some unanswered questions remain regarding its long-term effects on diabetic complications. Metabolic surgery and novel classes of glucose-lowering medications are currently the most effective interventions to induce weight loss and by extension remission in patients with diabetes; however, the ideal strategy to achieve the long-term maintenance of remission remains doubtful. In this narrative review, we discuss the available therapeutic approaches to target the remission of diabetes through personalized multimodal care, based on the latest evidence.

Remission of Type II Diabetes Mellitus 1-Year Postoperative Following One Anastomosis Gastric Bypass in Correlation with ABCD, DiaRem, and DRS Scores

BACKGROUND

Diabetes mellitus (DM) is a debilitating chronic illness. Roux en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) present a potential solution to type II DM. Several scoring systems predict DM remission as ABCD score, DiaRem score, and diabetes remission score (DRS).

STUDY DESIGN

This was a retrospective study that included 138 patients with DM and underwent OAGB. BMI, HbA1C, insulin, and oral hypoglycemics need were recorded pre- and postoperatively with calculation of ABCD, DiaRem, and DRS scores. Effects of OAGB on DM were observed and correlated with the scoring systems to detect their sensitivity and specificity.

RESULTS

Age, preoperative, and postoperative BMI were 47.38 ± 7.632, 45.096 ± 4.465, and 31.173 ± 3.799 respectively. The preoperative and stimulated C-peptides were 3.357 ± 0.995 and 4.158 ± 0.897 ng/ml respectively. The preoperative and postoperative HbA1C were 7.396 ± 0.743% and 6.564 ± 0.621% respectively. Patients with complete remission were 32 patients (23.2%) and with partial remission were 46 patients (33.3%) adding to 56.5% considered in remission. There was significant decrease of BMI, HbA1C, insulin, and oral hypoglycemic use postoperatively. Receiver operator characteristics (ROC) curve showed that ABCD, DiaRem, and DRS scores had AUC of 0.853 with cut-off > 5, 0.921 with cut-off ≤ 8, and 0.805 with cut-off ≤ 8 respectively. The DiaRem score had the highest AUC followed by ABCD score then DRS score.

CONCLUSION

OAGB significantly reduced BMI and HbA1C values 1 year postoperatively with 56.5% DM remission. DiaRem score had more remission predictive value following OAGB than ABCD and DRS scores especially when ≤ 8 with 90.6% sensitivity and 83% specificity.

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Predictors of Type 2 Diabetes Mellitus Remission After Metabolic Surgery in Asian Patients with a BMI < 32.5 kg/m2

BACKGROUND

Metabolic surgery is an effective treatment for type 2 diabetes mellitus (T2DM) in patients with obesity. However, the efficacy in patients with body mass index (BMI) < 32.5 kg/m², especially in Asian populations, has not been widely reported, and there are few studies on the prediction of diabetes remission.

METHODS

We evaluated 112 patients with T2DM who underwent metabolic surgery between October 2008 and November 2019. The basic data of the patients were collected, and clinical variables were measured at 6 months, 1 year, and 2 years after metabolic surgery. Four independent predictors of surgical outcomes were identified to construct the prediction score.

RESULTS

Diabetes remission occurred for 38 of the 112 patients. Ninety patients underwent Roux-en-Y gastric bypass, while the remaining 22 patients underwent sleeve gastrectomy. Weight, glucose, and lipid metabolism parameters were improved significantly after metabolic surgery. Age, BMI, insulin use, and duration were independent predictors of T2DM remission. The above four factors were defined with scores and developed ABID (age, BMI, insulin use, duration) scoring system. Patients with greater ABID scores had a greater probability of diabetes remission (from 0% at score 0 to 100% at score 4).

CONCLUSIONS

The ABID score is a simple and easy-to-implement prediction score system of diabetes remission after metabolic surgery for T2DM patients with a BMI < 32.5 kg/m².

Effect of roux-en Y gastric bypass surgery on patients with type 2 diabetes mellitus: A protocol of systematic review and meta-analysis

BACKGROUND

Previous studies have reported that roux-en Y gastric bypass surgery (RYGBS) can benefit patients with type 2 diabetes mellitus (T2DM). However, their conclusions are still inconsistent. Thus, this study will aim to assess the effect of RYGBS for patients with T2DM.

METHODS

In this study, the electronic databases of MEDLINE, EMBASE, CENTRAL, CINAHL, AMED, and CNKI from inceptions to the present without any limitations to language and publication status. All randomized controlled trials on assessing the effect of RYGBS for patients with T2DM will be included in this study. Two independent authors will carry out study search and selection according to the previous designed inclusion and exclusion criteria. At the same time, 2 authors will independently evaluate the risk of bias assessment by Cochrane risk of bias tool. Any disagreements between 2 authors will be solved by a third author through discussion. RevMan 5.3 software will be utilized for statistical analysis.

RESULTS

This study will summarize the most recent studies and will provide a deeper understanding about using the effect of RYGBS for patients with T2DM.

CONCLUSIONS

The findings of this study will present the existing evidence for the effect of RYGBS for patients with T2DM.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202040127.

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 and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, 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 health care 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.

Quality Assessment of Systematic Review of the Bariatric Surgery for Diabetes Mellitus

OBJECTIVE

Using the AMSTAR tool, this study evaluated the quality of systematic reviews (SRs) that assessed the efficacy of bariatric surgery in diabetic patients. We aimed to identify studies that can be used as clinical references.

METHODS

Medline (via PubMed), EMBASE, Epistemonikos, Web of Science, Cochrane Library, CBM, CNKI, and Wanfang Data were systematically searched from inception to December 31, 2017. Two reviewers independently selected SRs and extracted data. Disagreements were solved by discussions or through consultation with a third reviewer. Reviewers extracted data (characteristics of included SRs, e.g., publication year, language, and number of authors) into the predefined tables in the Microsoft Excel 2013 sheet. Data were visualized using the forest plot in RevMan 5.3 software.

RESULTS

A total of 64 SRs were included. The average AMSTAR score was 7.4 ± 1.7. AMSTAR scores of 7 (n = 21, 32.8%) and 8 (n = 14, 28.1%) were most common. The AMSTAR scores of SRs published before 2016 (n = 46, 71.9%) were compared with SRs published after 2016 (n = 18, 28.1%), and no significant differences were observed (MD = -0.79, 95% confidence interval (CI) -1.65-0.07, P = 0.07). For SRs published in Chinese (n = 17, 26.6%) compared to those published in English (n = 47, 73.4%), the AMSTAR scores significantly differed (MD = 0.21, 95% CI (-0.55, 0.97), P = 0.59). For SRs published in China (n = 33, 51.6%) compared to those published outside of China (n = 31, 48.4%), significant differences in the AMSTAR scores were observed (MD = 1.10, 95% CI (0.29, 1.91), P = 0.008). For SRs with an author number ≤ 6 (n = 31, 48.4%) compared to SRs with authors ≥ 6 (n = 33, 51.6%), no significant differences were observed (MD = -0.36, 95% CI (-1.22, 0.50), P = 0.41). For high-quality SRs published after 2016 (n = 11, 17.2%) compared to other SRs (n = 53, 82.8%), statistically significant differences were noted (MD = 1.75, 95% CI (1.01, 2.49), P < 0.00001).

CONCLUSIONS

The number of SRs assessing the efficacy of bariatric surgery in diabetic patients is increasing by year, but only a small number meet the criteria to support guideline recommendations. Study protocols not being registered, grey literature not retrieved, incorporation of grey literature as exclusion criteria, and failure to evaluate publication bias and report a conflict of interest were the main causes of low AMSTAR scores.

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.

Pros and cons of Roux en-Y gastric bypass surgery in obese patients with type 2 diabetes

INTRODUCTION

The worldwide prevalence of obesity and type 2 diabetes (T2D) constitutes an epidemic that is a threat to public health. Bariatric surgery, including Roux en-Y gastric bypass (RYGB), is currently the most effective treatment to induce long-term weight loss and remission of co-morbid conditions. Surgery, however, comes with an added risk of complications, highlighting the need to understand the comparative effectiveness and risks of surgical versus conventional approaches to the treatment of obesity and T2D.

AREAS COVERED

Positive and negative outcomes of RYGB surgery in patients with T2D are assessed, with a primary focus on RYGB surgery versus standard non-surgical treatment of obese patients with T2D in randomized clinical trials or high-quality observational cohorts. Searches were conducted in the PubMed database up to 11 April 2019 for relevant studies.

EXPERT OPINION

High-level evidence reveals that RYGB ameliorates the clinical manifestations of T2D to a significantly higher degree than medical therapy. Postoperative incidence of beneficial effects and complications, however, differ across subgroups of patients with different preoperative characteristics. Key knowledge gaps, particularly on long-term complications, microvascular- and macrovascular events, and mortality should be addressed, so treatment with RYGB can be applied in an individualized approach to maximize benefits and minimize complications.

Integrating medical and surgical therapies to optimize the outcomes of type 2 diabetes

Modern treatment of type 2 diabetes must rely on therapy individualization. Morbid obesity confers an independent excess of risk to diabetes. In these individuals metabolic surgery is an opportunity the physician should consider, especially at the time of the diabetes diagnosis, because of its efficacy and long-term effects. In addition to the possible remission of diabetes, bariatric surgery is also associated with reduced risk of micro- and macrovascular complications. A multidisciplinary team approach is necessary to maximize the beneficial effects and minimize the adverse events of metabolic surgery and to ensure proper follow-up based on the residual possibility of developing complications. In this regard, a consensus on definition of remission must be reached to define the residual risk after antidiabetic drug withdrawal. Finally, randomized clinical trials are deemed necessary to establish the risk-to-benefit profile of glucose-lowering agents for those patients who have remained diabetic or experience a disease relapse.

"Dual-remission" after Roux-en-Y gastric bypass surgery: Glycemic variability cannot always be improved in Chinese obese patients with type 2 diabetes

BACKGROUND

Glycemic variability after Roux-en-Y Gastric Bypass (RYGB) has not been adequately examined in Chinese obese patients with type 2 diabetes (T2D).

OBJECTIVE

We aimed to evaluate glucose variability after RYGB by continuous glucose monitoring (CGM) and then evaluate the remission rate based on the complete diabetes remission criteria combined with normal ranges of CGM for the Chinese population, which we defined as "dual-remission."

SETTING

The study was done at our academic university-affiliated hospital.

METHODS

Over a 3-day period, CGM was performed on 43 Chinese obese T2D patients combined with a mixed-meal test before and 1 year after RYGB. Mean amplitude of glucose excursions (MAGE), standard deviations (SD), and the time that patients' blood glucose levels were≥7.0 mmol/L,≥7.8 mmol/L,≥11.1 mmol/L, and≤3.9 mmol/L within 24 hours was analyzed. Multiple logistic regression analyses were used to identify predictors of "dual-remission."

RESULTS

Complete diabetes remission was achieved in 27 patients (62.8%) 1 year after RYGB. However, MAGE didn't change in the group, and only 18.6% patients met "dual-remission." Compared with patients in the complete remission group, patients in the dual-remission group had a shorter duration of diabetes, younger age, lower glycated hemoglobin (HbA1c) level, and no insulin usage at baseline. Correlation analysis showed MAGE after RYGB was positively correlated with diabetes duration (r = .43, P<.01). Multiple logistic regressions indicated a shorter duration was associated with a higher possibility to achieve dual-remission after adjusting for age, gender, HbA1c, and insulin therapy.

CONCLUSION

Glucose variability can't be effectively improved in most Chinese obese diabetic patients after RYGB. Shorter diabetes duration was associated with higher possibility to achieve "dual-remission."