A comparison of a personal series of biliopancreatic diversion and literature data on gastric bypass help to explain the mechanisms of resolution of type 2 diabetes by the two operations

The effect of the COVID-19 pandemic on bariatric surgery delivery in Edmonton, Alberta: a single-centre experience

Delays in the delivery of bariatric surgery in Canada in the context of the COVID-19 pandemic have not been previously explored. Understanding the potential barriers associated with these delays may help in the implementation and delivery of enhanced bariatric protocols, thereby minimizing health care system burden and improving bariatric delivery. We present the experience of a single high-volume, accredited bariatric program in Edmonton, Alberta, in 2020. Although reductions in bariatric cases occurred during lockdown months, the overall number of cases was comparable to 2019 owing to the adoption of strategies aimed at offsetting the burden of hospital resources. These strategies included optimizing patient selection, implementing bariatric Enhanced Recovery After Surgery protocols, and minimizing unnecessary postoperative investigations to allow most patients to be discharged on postoperative day 1. We advocate to continue optimizing bariatric delivery in the face of the COVID-19 pandemic that so disproportionally affects those with severe obesity and its metabolic complications.

Case Report: Extensive Dermatitis Secondary to Severe Malnutrition, Zinc and Vitamin Deficiencies After Malabsorptive Bariatric Surgery

Bariatric surgery is one of the most effective treatments currently available for obesity and its derived comorbidities. However, complications may occur, especially when malabsorptive surgeries like a biliopancreatic diversion is performed. We present the case of a female patient whose obesity was treated with this technique, and in the 9^th year of follow-up developed an extensive dermatitis secondary to zinc deficiency and malnutrition, precipitated by therapeutic non-compliance. A close surveillance of early symptoms and signs of nutritional deficiencies as well as chronic supplementation of vitamins and trace elements is required; this case illustrates the relevance of periodical, lifelong visits to a medical physician with special training and experience in the management of post bariatric surgery patients in order to prevent, diagnosis and early treat related complications.

Ten-year remission rates in insulin-treated type 2 diabetes after biliopancreatic diversion with duodenal switch

BACKGROUND

Biliopancreatic diversion with duodenal switch (BPD-DS) confers the highest rate of type 2 diabetes (T2D) remission compared with other bariatric procedures. Previous studies suggest that type of antidiabetic therapy used before surgery and duration of disease influence postsurgical glycemic outcomes. Short-term, progressive improvement in insulin sensitivity and beta-cell function after metabolic surgery in patients with noninsulin-treated T2D has been demonstrated. Whether patients with more advanced disease can achieve sustained remission remains unclear.

OBJECTIVE

The aim of this study was to assess long-term glycemic outcomes in insulin-treated patients with T2D after BPD-DS and identify predictors of sustained diabetes remission or relapse.

SETTING

University-affiliated tertiary care center.

METHODS

Data from 141 patients with insulin-treated T2D who underwent BPD-DS between 1994 and 2006 with 10 years of follow-up data were collected from a prospective electronic database.

RESULTS

Follow-up was available in 132 patients (91%). At 10 years after metabolic surgery, 90 patients (68.1%) had a complete remission of diabetes, 3 (2.3%) had a partial remission, 21 (15.9%) had an improvement, and 3 (2.3%) were unchanged in their diabetes status. Fourteen patients died during the 10-year follow-up period. Relapse after an initial period of remission occurred in 15 (11.4%) patients. Insulin discontinuation was achieved in 97%. Duration of diabetes was an independent predictor of nonremission at 10 years.

CONCLUSIONS

The BPD-DS maintains remission at 10 years postoperatively in patients with more advanced diabetes. Long-term benefits of the BPD-DS on weight loss and glycemic control should be considered when offering metabolic surgery to patients with insulin-treated T2D.

Biliopancreatic Diversion in the Surgical Treatment of Morbid Obesity: Long-Term Results and Metabolic Consequences

PURPOSE

In the multidisciplinary therapeutic approach to obesity, bariatric surgery is considered the most effective treatment in weight reduction and the decrease in associated comorbidities. The objective of this work is to describe the long-term clinical and metabolic results in obese patients undergoing biliopancreatic diversion (BPD) according to Scopinaro's technique.

MATERIALS AND METHODS

Patients undergoing surgery were followed by the same multidisciplinary team in a study period of 15 years (1999-2015). A retrospective study based on a prospective database was designed, where data on the evolution of obesity-related diseases and nutritional parameters were studied.

RESULTS

Two hundred seventy-seven patients were collected; 75.5% were women. The preoperative body mass index (BMI) decreased from 52.5 kg/m² to 34.9 kg/m² 10 years after surgery. A resolution or improvement of diabetes has been observed in 85.38% of the patients; a decrease in arterial hypertension and obstructive sleep apnea syndrome were in 65.61% and 89.14%, respectively. Throughout the monitoring of the sample, protein malnutrition increased, from 1.8% after the first year of surgery to 4.5% 10 years after the operation.

CONCLUSION

Even if Scopinaro's technique is beginning to be replaced by other malabsorptive techniques, it can still be considered as an effective surgical procedure in terms of weight loss, quality of life, and evolution of obesity-related diseases. In order to avoid nutritional deficiencies, the operated patients need a strict follow-up and a supplementation adjusted to the technique.

Predictors of remission of type 2 diabetes mellitus in obese patients after gastrointestinal surgery

BACKGROUND

Gastroenterology is a beneficial treatment of morbidly obese type 2 diabetes mellitus (T2DM). We aimed to identify the predictors for the treatment of T2DM obese patients.

METHODS

A retrospective study consisting of 531 patients undergoing laparoscopic gastric banding (LGB), laparoscopic mini-gastric bypass (LMGB) and laparoscopic sleeve gastrectomy (LSG) from January 2004 to May 2007 was performed. Patients with preoperative fasting serum glucose concentration of more than 126 mg/dl were diagnosed as T2DM. A postoperatively fasting serum glucose level of less than 110 mg/dl was considered to be remission of T2DM.

RESULTS

Of the 531 patients, 62 (11.6%) were diagnosed as T2DM, including 23 men and 39 women, with a mean age of 31.8 ± 9.2 years, and a mean body mass index (BMI) of 40.0 kg/m(2). The mean glucose at 3, 6, and 12 months after surgery were 100.1 mg/dl, 95.1 mg/dl and 91.8 mg/dl, respectively. The mean body weight loss one year after surgery was 9.4% for LGB, 31.4% for LSG and 37.1% for LMGB, respectively. Among these operation methods (LGB, LMGB and LSG), the BMI, body weight, waist circumference, serum lipid profile and serum factors associated with glucose metabolism were significantly different during the one-year postoperative follow-up. Remission rate of T2DM was achieved in 84.8%, 58.8% and 58.3% of patients for LMGB, LGB and LSG, respectively. The best operative method for the remission of T2DM was LMGB. Using an artificial neural network (ANN) data mining technique, waist circumference, operative methods and C-peptide were significantly predictors for the remission of T2 DM.

CONCLUSION

One year after gastrointestinal surgery, improvement of serum lipid profiles and serum data related to glucose metabolism in the different operative methods were noticed. LMGB seems to be the most effective procedure for the reduction of serum glucose levels compared with LAGB and LSG.

Effects of gastric bypass on type 2 diabetes in patients with BMI 30 to 35

BACKGROUND

This study aims to investigate if the benefits on glycemic control following Roux-en-Y gastric bypass (RYGB) in morbidly obese type 2 diabetes (T2DM) patients are maintained in the 30-35 kg/m(2) BMI (body mass index) range, comparing results with those in literature.

METHODS

The study participants were twenty T2DM patients aging 35-70 years, BMI 30.0-34.9 kg/m(2), minimum diabetes duration 3 years, glycosylated haemoglobin (HbA1c) ≥7.5% despite good clinical practice medical therapy, submitted to laparoscopic RYGB, and monitored during 36 months. Twenty-seven matched diabetic patients as controls.

RESULTS

Five females, mean age 57 (42-69) years, weight 96.0 (70-111) kg, BMI 32.9 (30.3-34.9) kg/m(2), waist circumference 112 (100-128) cm, diabetes duration 14 (3-28) years, HbA1c 9.5 (7.5-14.2) %, and C-peptide 3.2 (1,6-9.1) mcg/l. Ten patients were on insulin. There was no mortality, and there were two major late complications. BMI and waist decreased stabilizing around 25 kg/m(2) and 92 cm. Fasting serum glucose and HbA1c reached values around 150 mg/dl and 7%, which subsequently maintained. There was remission in 25% of cases, control 45%, and all the others improved. HOMA-IR and insulin sensitivity index normalized at 1 month, then maintained. AIR and insulinogenic index showed no postoperative changes. Diabetes remission correlated negatively with duration (p < 0.05; r (2) = 0.61), while control positively with C-peptide (p < 0.05; r (2) = 0.19). In the control group, FSG, HbA1c, serum triglyceride, and cholesterol significantly decreased with considerable progressive increase of antidiabetic/antihyperlipemic therapy. All patients had HbA1c >7% at 2-3 years.

CONCLUSIONS

Glycemic control obtained by RYGB in this study was less good than that reported by others, apparently due to different patient selection criteria. Our results do not support RYGB weight loss-independent effect on beta-cell function in the T2DM patients with BMI 30-35 kg/m(2).

Predictors for remission of major components of the metabolic syndrome after biliopancreatic diversion with duodenal switch (BPDDS)

BACKGROUND

Metabolic surgery causes the remission of type 2 diabetes mellitus (T2DM), hypertension, and hyperlipidemia to varying degrees, depending on the patient characteristics and the surgical procedure. The aim of this study was to find predictors for the remission of T2DM and hypertension after biliopancreatic diversion with duodenal switch (BPDDS).

METHODS

Eighty patients with T2DM were followed up for 2 years or more after BPDDS, and changes in body weight and metabolic status were noted. Remission was defined as fasting glucose <7 mmol/l with HbA1C <6.5 %, blood pressure <140/90 mmHg, and low-density lipoprotein (LDL) <2.6 mmol without the use of medication.

RESULTS

Preoperatively, the mean age was 44 years, body mass index (BMI) was 48 kg/m(2), and duration of diabetes was 5 years. Of the 80 patients, 38 patients were using insulin, 48 patients were using antihypertensives, and 38 patients were using a lipid-lowering drug. Five percent of the patients had recommended levels for HbA1C, blood pressure, and LDL prior to the operation. The remission rate at 2 years was 94 % for T2DM, 54 % for hypertension, and 86 % for LDL hyperlipidemia. Preoperative predictors for nonremission of T2DM were a higher BMI, insulin usage, and low insulin C-peptide, and for hypertension, older age and more severe hypertension. Postoperative weight loss was important for both.

CONCLUSIONS

Surgical intervention with BPDDS is an effective treatment of T2DM, hypertension, and hyperlipidemia. The duration of T2DM and age of the patient are the most important preoperative predictors for the remission of T2DM and hypertension, respectively.

Biological effects of bariatric surgery on obesity-related comorbidities

The prevalence of obesity has increased so rapidly over the last few decades that it is now considered a global epidemic. Obesity, defined as a body mass index (BMI) of 30 or more, is associated with several comorbid conditions that decrease life expectancy and increase health care costs. Diet therapies have been reported to be ineffective in the long-term treatment of obesity, and guidelines for the surgical therapy of morbid obesity (BMI ≥ 40 or BMI ≥ 35 in the presence of substantial comorbidities) have since been established. Considering the number of bariatric surgical procedures has dramatically increased since these guidelines were established, we review the types of bariatric surgical procedures and their impact on diabetes, sleep apnea, dyslipidemia and hypertension - 4 major obesity-related comorbidities.

Vagal blocking improves glycemic control and elevated blood pressure in obese subjects with type 2 diabetes mellitus

BACKGROUND

An active device that downregulates abdominal vagal signalling has resulted in significant weight loss in feasibility studies.

OBJECTIVE

To prospectively evaluate the effect of intermittent vagal blocking (VBLOC) on weight loss, glycemic control, and blood pressure (BP) in obese subjects with DM2.

METHODS

Twenty-eight subjects were implanted with a VBLOC device (Maestro Rechargeable System) at 5 centers in an open-label study. Effects on weight loss, HbA1c, fasting blood glucose, and BP were evaluated at 1 week to 12 months.

RESULTS

26 subjects (17 females/9 males, 51 ± 2 years, BMI 37 ± 1 kg/m(2), mean ± SEM) completed 12 months followup. One serious adverse event (pain at implant site) was easily resolved. At 1 week and 12 months, mean excess weight loss percentages (% EWL) were 9 ± 1% and 25 ± 4% (P < 0.0001), and HbA1c declined by 0.3 ± 0.1% and 1.0 ± 0.2% (P = 0.02, baseline 7.8 ± 0.2%). In DM2 subjects with elevated BP (n = 15), mean arterial pressure reduced by 7 ± 3 mmHg and 8 ± 3 mmHg (P = 0.04, baseline 100 ± 2 mmHg) at 1 week and 12 months. All subjects MAP decreased by 3 ± 2 mmHg (baseline 95 ± 2 mmHg) at 12 months.

CONCLUSIONS

VBLOC was safe in obese DM2 subjects and associated with meaningful weight loss, early and sustained improvements in HbA1c, and reductions in BP in hypertensive DM2 subjects. This trial is registered with ClinicalTrials.gov NCT00555958.

Biliopancreatic diversion with transient gastroplasty and duodenal switch: long-term results of a multicentric study

BACKGROUND

Over the years, several modifications of the Scopinaro biliopancreatic diversion (BPD) have been proposed. This retrospective study reported the results of 15 years of follow-up after open BPD coupled with a type of transient gastroplasty (TG) and duodenal switch (DS), termed BPD-TG with DS.

METHODS

Data were analyzed for 874 patients operated on between January 1993 and May 2010 in 3 different surgical departments.

RESULTS

The median preoperative body mass index (BMI) was 52 kg/m² (range, 35-63). Comorbidities present were hypertension (57%), hypercholesterolemia (87%), hypertriglyceridemia (53%), type 2 diabetes (35%), and obstructive sleep apnea syndrome (OSAS; 9%). The mean follow-up was 11.9 ± 3.1 years. The median BMI decreased to 33.9 after 1 year from bariatric surgery, 31.1 after 2-5 years, 30.9 after 5-10 years, and 31.2 kg/m² after 10-15 years. Overall, 67% of diabetic patients were able to stop insulin and 97% were able to stop oral hypoglycemic drugs within 1 year. Blood pressure, triglyceride levels, and cholesterol levels became normal in >96% of patients within 1 year. OSAS was resolved within 8 months in all cases. One year postoperatively, but absent thereafter, we observed severe hypoalbuminemia (serum albumin <3 g/dL) in 1.7% of patients and severe iron-deficiency anemia in 1.9%. Incisional hernias were recorded in 30% and anastomotic ulcers in 2.4% of cases. Mortality was null.

CONCLUSION

Our results suggest considering BPD-TG with DS as a viable bariatric operation, with its excellent long-term outcome in terms of weight loss, improvement of obesity-related diseases, and quality of life.

Effects of bariatric surgery on glucose homeostasis and type 2 diabetes

Obesity is an important risk factor for type 2 diabetes mellitus (T2DM). Weight loss improves the major factors involved in the pathogenesis of T2DM, namely insulin action and beta cell function, and is considered a primary therapy for obese patients who have T2DM. Unfortunately, most patients with T2DM fail to achieve successful weight loss and adequate glycemic control from medical therapy. In contrast, bariatric surgery causes marked weight loss and complete remission of T2DM in most patients. Moreover, bariatric surgical procedures that divert nutrients away from the upper gastrointestinal tract are more successful in producing weight loss and remission of T2DM than those that simply restrict stomach capacity. Although upper gastrointestinal tract bypass procedures alter the metabolic response to meal ingestion, by increasing early postprandial plasma concentrations of glucagon-like peptide 1 and insulin, it is not clear whether these effects make an important contribution to long-term control of glycemia and T2DM once substantial surgery-induced weight loss has occurred. Nonetheless, the effects of surgery on body weight and metabolic function indicate that bariatric surgery should be part of the standard therapy for T2DM. More research is needed to advance our understanding of the physiological effects of different bariatric surgical procedures and possible weight loss-independent factors that improve metabolic function and contribute to the resolution of T2DM.

Incretins and their influence on the course of type 2 diabetes in patients with morbid obesity after bariatric oper

Most researchers support the important role of incretins, particularly glucagon-like peptide-1 in improving metabolic control in patients with type 2 diabetes after bariatric operations, mostly involving shunting. A positive effect of bariatric surgery for type 2 diabetes is known from numerous publications on the results of surgical treatment of morbid obesity and in this review we try to analyze the mechanisms of this effect.

The effects of biliopancreatic diversion on type 2 diabetes mellitus in patients with mild obesity (BMI 30-35 kg/m2) and simple overweight (BMI 25-30 kg/m2): a prospective controlled study

BACKGROUND

Beneficial effects of BPD on T2DM in BMI >35 kg/m(2) patients are far better than those in patients with BMI 25-35. This study was aimed at investigating if a similar difference exists between patients with mild obesity (OB, BMI 30-35) or simple overweight (OW, BMI 25-30).

METHODS

Fifteen OB (six M) and 15 OW (13 M), diabetic for ≥ 3 years, with HbA1c ≥ 7.5% despite medical therapy, underwent BPD. OB/OW: age 55.1 ± 8.0/57.8 ± 6.7 years, BMI 33.1 ± 1.5/28.0 ± 1.3 kg/m(2), diabetes duration 11.6 ± 8.0/11.1 ± 6.1 years, insulin therapy 4/8 p. FSG and HbA1c were determined preoperatively and up to 2 years. Insulin resistance and beta-cell function were explored by means of HOMA-IR and IVGTT (AIR). Thirty-eight diabetic patients on medical therapy served as controls.

RESULTS

Mean BMI stabilized around 27 since the 4th month in OB, and 24 since 1st month in OW. FSG in OB/OW preop, 1, 12, 24 months: 234 ± 76/206 ± 62 mg/dL, 154 ± 49/176 ± 75, 131 ± 32/167 ± 48, 134 ± 41/154 ± 41 (cross-sectional n.s. at all times); HbA1c: 9.5 ± 1.6/9.1 ± 1.3, 7.3 ± 1.1/7.3 ± 1.2, 5.9 ± 0.6/7.1 ± 1.1 (p < 0.01), 5.9 ± 0.9/6.9 ± 1.1 (p < 0.01). HOMA-IR, preoperatively 10.7 ± 5.8/7.5 ± 5.4, went below 3.0 at 1 month and remained such until 2 years in both groups. AIR, preoperatively 1.11 ± 3.17/1.27 ± 2.68 μIU/mL, in OB significantly increased at 4 months to 7.63 ± 5.79, maintained up to 2 years with 6.95 ± 3.19, whereas in OW, statistical significance was reached only at 2 years with 5.02 ± 4.87.

CONCLUSIONS

Significantly different BPD effect, thus biological severity of T2DM, also exists between mildly obese and simply overweight patients. The rise of AIR allows hoping that an increase of beta-cell mass may occur in the long run.

Temporal changes in glucose and insulin homeostasis after biliopancreatic diversion and laparoscopic adjustable gastric banding

BACKGROUND

Obesity surgery is associated with improvement in type 2 diabetes mellitus. Our aim was to examine the effects of biliopancreatic diversion (BPD) and laparoscopic adjustable gastric banding (LAGB) on the body mass index, fasting insulin level, glucose level, and insulin resistance in morbidly obese subjects with type 2 diabetes mellitus. The setting was the Department of Surgery, Morriston Hospital (Swansea, Wales, United Kingdom).

METHODS

A total of 13 morbidly obese patients (7 BPD, 6 LAGB) underwent serial measurements of fasting glucose and insulin at baseline, immediately after surgery (days 1-7), and 1, 6, and 12 months postoperatively. The homeostasis model of assessment-insulin resistance was calculated.

RESULTS

In the BPD group, the glucose levels had normalized by day 3 (5.6 ± 1 mmol/L) and the difference was statistically significant at 6 and 12 months postoperatively (5 ± .7 and 4.4 ± .5 mmol/L, respectively). The insulin levels had improved from day 1, and the difference was statistically significant at days 2, 5, 6, and 7 (19 ± 9, 14.2 ± 7, 15.2 ± 8, and 17.4 ± 8 mU/L, respectively). All diabetes medications were stopped on the fourth postoperative day. In the LAGB group, no statistically significant changes were seen in the glucose levels. Statistically significant changes in insulin were seen on days 1 and 2 (19 ± 13 and 13 ± 6.5 mU/L, respectively). The homeostatic model of assessment-insulin resistance had improved in both groups (BPD, 1.6 ± 1.2, P < .01; and LAGB, 4.3 ± 1.4, P < .05).

CONCLUSION

BPD causes immediate remission of type 2 diabetes mellitus. Leptin might play an important role in the early improvement of insulin resistance in fasting states after BPD. In the LAGB group, glucose homeostasis improved, but the patients still required diabetes medications, although the dosages were reduced.

Metabolic surgery-principles and current concepts

INTRODUCTION

In the almost six decades of bariatric surgery, a variety of surgical approaches to treating morbid obesity have been developed.

HISTORY AND EVOLUTION

Rather than prior techniques being continually superseded by new ones, a broad choice of surgical solutions based on restrictive, malabsorptive, humoral effects, or combinations thereof, is now available. In fact, in recent years, the advent of surgically modifying human metabolism promises new approaches to ameliorate traditionally medically treated metabolic entities, i.e., diabetes, even in the non-obese. The understanding of the various metabolic effects have led to a paradigm shift from bariatric surgery as a solely weight-reducing procedure to metabolic surgery affecting whole body metabolism.

CONCLUSION

The bariatric surgeon now faces the challenge and opportunity of selecting the most suitable technique for each individual case. To assist in such decision-making, this review, Metabolic surgery-principles and current concepts, is presented, tracing the historical development; describing the various surgical techniques; elucidating the mechanisms by which glycemic control can be achieved that involve favorable changes in insulin secretion and insulin sensitivity, gut hormones, adipokines, energy expenditure, appetite, and preference for low glycemic index foods; as well as exploring the fascinating future potential of this new interdisciplinary field.

Long-term results of biliopancreatic diversion with or without gastric preservation for morbid obesity

We aimed at comparing our long-term results after biliopancreatic diversion (BPD) with or without gastric preservation for morbid obesity. Between 1999 and 2009, we performed 540 BPD: 287 patients (group A) underwent BPD with distal gastric resection (BPD-AHS) and 253 (group B) underwent BPD associated with transitory vertical gastroplasty (TGR) with duodenal switch (DS). The results have been analyzed in terms of weight loss, improvement of comorbidities, and quality of life (Bariatric Analysis and Reporting Outcome System). The mean follow-up was 7.4 ± 2.9 years. One year after surgery, mean initial excess weight loss percentage was 69% for patients in group A (n = 287) and 65% for group B (n = 253); after 2-5 years, it was 74% for patients who underwent BPD-AHS (n = 130) and 75% for patients who underwent BPD-TGR-DS (n = 116); it was 71% and 74% for patients in group A (n = 157) and B (n = 137), respectively, followed up for >5 years (P = 0.27). Among the diabetic patients in both groups (191 patients), 64% discontinued the medication with insulin (P = 0.25), and 98% had stopped oral drugs within 1 year from surgery (P = 0.29). We did not observe deficiencies of vitamins and proteins. The overall incidence of incisional hernias was 38% (P = 0.35). We recorded 13 anastomotic ulcers (2.4%; P = 0.28). BPD represents, in spite of the side effects, an effective technique for treatment of morbid obesity and its associated diseases. Moreover, our results showed that patients who underwent BPD-TGR-DS had slightly better results in terms of postoperative metabolic complications and improvement in quality of life.

Metabolic syndrome after bariatric surgery. Results depending on the technique performed

BACKGROUND

There is a lack of long-term studies for metabolic syndrome after bariatric surgery. Our aim is to show the evolution of the parameters that define the metabolic syndrome after bariatric surgery, up to 10 years of follow-up, in order to clarify what technique gets better results with fewer complications.

METHODS

The IDF definition of the metabolic syndrome was used for this study. One hundred twenty-five morbid obese and superobese patients underwent vertical banded gastroplasty. Two hundred sixty-five morbid obese and superobese patients had biliopancreatic diversion (Scopinaro and modified biliopancreatic diversions), and 152 morbid obese patients underwent laparoscopic gastric bypass. A mean follow-up of up to 7 years was done in all groups.

RESULTS

Prior to surgery, metabolic syndrome was diagnosed in 114 patients of Scopinaro group (76%), in 85 patients of modified biliopancreatic diversion group (73.9%), in 81 patients of laparoscopic gastric bypass (53.4%), and in 98 patients of vertical banded gastroplasty (78.4%). When metabolic syndrome parameters were evaluated at 7 years of follow-up, owing to weight gain, these results changed nearby to preoperative values in both laparoscopic gastric bypass and vertical banded gastroplasty groups.

CONCLUSION

According to our results, the best technique to resolve metabolic syndrome is the modified biliopancreatic diversion. Due to its high morbidity, it only must be considered in superobese patients. In obese patients, the laparoscopic gastric bypass may be a less agressive choice, but it should be coupled with lifestyle changes to keep away from the weight gain in the long run. Restrictive procedures may be indicated only in a few well-selected cases.

Remission of type 2 diabetes mellitus following bariatric surgery: review of mechanisms and presentation of the concept of 'reversibility'

PURPOSE OF REVIEW

Roux-en-Y gastric bypass (RYGB) leads to remission of type 2 diabetes mellitus (T2DM) in a majority of patients. This is prompting investigation of RYGB, and other bariatric operations as interventional therapies for T2DM.

RECENT FINDINGS

The impact of RYGB is due to an increase in the release of gastrointestinal hormones in response to a meal [glucagon-like peptide, peptide YY, oxyntomodulin]. This effect involves the parasympathetic nervous system. These same hormones are responsible for an early increase in β-cell secretion of insulin, leading to early remission of T2DM following RYGB. Progressive weight loss leads to a later improvement in peripheral insulin sensitivity, which is required for later remissions, and is responsible for re-emergence of T2DM in individuals who regain weight in long-term follow-up. As the success of bariatric surgery has prompted the emergence of the concept that T2DM is reversible, we offer a theory to predict reversibility of diabetes after bariatric surgery that is based on baseline beta cell function.

SUMMARY

This review will improve the understanding of the physiology of bariatric surgery and its impact on T2DM, stimulate investigations into new avenues to treat T2DM, and allow better selection of nonobese individuals for interventional therapy of T2DM.

Resolution of type 2 diabetes following bariatric surgery: implications for adults and adolescents

Bariatric surgery is now widely reported to ameliorate or resolve type 2 diabetes mellitus in adults. Some clinical investigators even suggest its use as an early therapeutic intervention for type 2 diabetes in patients not meeting standard criteria for bariatric surgery. However, little is known about the exact mechanisms explaining the metabolic consequences, and much active investigation is underway to identify hormonal changes leading to diabetes resolution. This review includes a detailed description of various bariatric surgical procedures, including the latest less-invasive techniques, and a summary of current data providing insight into the short- and long-term metabolic effects. We outline current hypotheses regarding the mechanisms by which these surgical procedures affect diabetes and report on morbidity and mortality. Finally, we discuss the available data on bariatric surgery in adolescent patients, including special considerations in this potentially vulnerable population.

Conversion of failed vertical banded gastroplasty to biliopancreatic diversion, a wise option

BACKGROUND

Reoperations due to failures constitute an essential but challenging part of bariatric surgery practice today. The aim of this study was to evaluate the perioperative safety, efficacy, and postoperative quality of life in patients with biliopancreatic diversion (BPD), after failed vertical banded gastroplasty (VBG).

METHODS

Twelve patients after failed or complicated VBG, eight females and four males, median age 45 years (range 39-52), median body mass index (BMI) 46.39 kg/m2 (range 25.89-69.37), who underwent conversion to BPD, were studied.

RESULTS

Ten patients due to weight regain and two patients because of severe stenosis of the gastric pouch outlet were submitted in conversion to BPD. In eight (66.6%) patients the primary VBG had been followed by at least one revisional operation due to inadequate weight loss. The 10 patients after failed VBG, reached the lowest BMI recorded after VBG in just a year after BPD (p=0.721 for the comparison between the two time points). The two patients with stomal stenosis regained weight in the first six postoperative months and remain stable since then. Regarding safety, one major perioperative complication (gastrojejunostomy stenosis) occurred. At a median follow-up of 21 months (range 12-30) six complications have been documented, including a case of incisional hernia, four cases of pouch gastritis and a case of intractable iron-deficiency anemia.

CONCLUSION

Our early results indicate that conversion of failed VBG to BPD is highly effective with acceptable morbidity. Our data show that the effect on weight is strongly dependent on the indication for the conversion. Conversion to BPD, in such a group of patients, is a wise alternative, since it may reduce operative risks.

Bariatric surgery in patients with type 2 diabetes: benefits, risks, indications and perspectives

Obesity plays a key role in the pathophysiology of type 2 diabetes (T2DM), and weight loss is a major objective, although difficult to achieve with medical treatments. Bariatric surgery has proven its efficacy in obtaining marked and sustained weight loss, and is also associated with a significant improvement in glucose control and even diabetes remission. Roux-en-Y gastric bypass appears to be more effective in diabetic patients than the restrictive gastroplasty procedure. This may be explained not only by greater weight reduction, but also by specific hormonal changes. Indeed, increased levels of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) may lead to improved beta-cell function and insulin secretion as well as reduced insulin resistance associated with weight loss. The presence of T2DM in obese individuals is a further argument to propose bariatric surgery, and even more so when diabetes is difficult to manage by medical means and other weight-related complications may occur. Bariatric surgery is associated with a better cardiovascular prognosis and reduced mortality, even though acute and long-term complications are present. The observation that surgical rerouting of nutrients triggers changes in the release of incretin hormones that, in turn, ameliorate the diabetic state in the absence of weight loss has led to the recent development of innovative surgical procedures. Thus, bariatric surgery may be said to be progressing towards so-called 'metabolic surgery', which merits further evaluation in patients with T2DM within a multidisciplinary approach that involves both surgeons and endocrinologists.

Mechanisms of early improvement/resolution of type 2 diabetes after bariatric surgery

Bariatric surgery represents the main option for obtaining substantial and long-term weight loss in morbidly obese subjects. In addition, malabsorptive (biliopancreatic diversion, BPD) and restrictive (roux-en-Y gastric bypass, RYGB) surgery, originally devised to treat obesity, has also been shown to help diabetes. Indeed, type 2 diabetes is improved or even reversed soon after these operations and well before significant weight loss occurs. Two hypotheses have been proposed to explain the early effects of bariatric surgery on diabetes--namely, the hindgut hypothesis and the foregut hypothesis. The former states that diabetes control results from the more rapid delivery of nutrients to the distal small intestine, thereby enhancing the release of hormones such as glucagon-like peptide-1 (GLP-1). The latter theory contends that exclusion of the proximal small intestine reduces or suppresses the secretion of anti-incretin hormones, leading to improvement of blood glucose control as a consequence. In fact, increased GLP-1 plasma levels stimulate insulin secretion and suppress glucagon secretion, thereby improving glucose metabolism. Recent studies have shown that improved intestinal gluconeogenesis may also be involved in the amelioration of glucose homoeostasis following RYGB. Although no large trials have specifically addressed the effects of bariatric surgery on the remission or reversal of type 2 diabetes independent of weight loss and/or caloric restriction, there are sufficient data in the literature to support the idea that this type of surgery--specifically, RYGB and BPD--can lead to early improvement of glucose control independent of weight loss.

Obesity and bariatric surgery

Laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are the most commonly performed weight reduction operations in the United States. Preoperative assessment and selection should be performed by a multidisciplinary team to obtain optimal results. The most devastating complication of bariatric surgery is leak, which can carry a high risk of mortality if not detected and treated expediently. New nationwide databases have been developed to monitor outcomes and facilitate better understanding of the mechanisms of bariatric surgery. New horizons for the advancement of bariatric surgery are in the realm of surgery in adolescent and geriatric populations, the use of weight-loss surgery in lower body mass index (<35 kg/m(2)) populations, and the use of surgery to cure the comorbidities of obesity.

The surgical approach to management of pediatric obesity: when to refer and what to expect

Weight loss surgery is recommended for adult patients with morbid obesity and has been used on a case by case basis in the pediatric population. Surgery, however,is just a tool added to the two mainstays of therapy for obesity: 1.) controlled dietary intake and 2.) increases inactivity and exercise behaviors. For the pediatric population,the health consequences of obesity are profound with increased cardiovascular risk during adolescence and increased mortality in adulthood. Currently accepted guidelines for weight loss surgery referral use BMI cut points that are the same as for adults: BMI > or = 35 kg/m(2) and serious comorbidities of obesity or BMI > or = 40 kg/m(2) with minor comorbidities of obesity. A multidisciplinary approach to weight management must be utilized, and a lifetime of follow-up must be addressed. The most commonly performed operations for obesity are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). LAGB is safer and does not permanently alter gastrointestinal continuity; however, LAGB is not currently approved for implantation in adolescent patients. LRYGB involves a complex, permanent altering of the gastrointestinal anatomy and is associated with more complications around the time of surgery and is not subject to FDA approval because there is no associated implant. In each operation, appetite is suppressed by construction of a virtual (LAGB) or real(LRYGB) pouch. The dynamics and speed of appetite suppression and, consequently, weight loss are typically different for each operation though longer-term outcomes may be similar. Short- and long-term risks of surgery must be carefully weighed against the benefits of the associated weight loss for each patient. The patient must be empowered to understand the importance of lifestyle and behavior in achieving long-term health.

Bariatric surgery: risks and rewards

CONTEXT

Over 23 million Americans are afflicted with severe obesity, i.e. their body mass index (in kilograms per square meter) values exceed 35. Of even greater concern is the association of the adiposity with comorbidities such as diabetes, hypertension, cardiopulmonary failure, asthma, pseudotumor cerebri, infertility, and crippling arthritis.

OBJECTIVE

Diets, exercise, behavioral modification, and drugs are not effective in these individuals. This article examines the effect of surgery on the control of the weight and the comorbidities, as well as the safety of these operations.

INTERVENTIONS

Although the article focuses on the outcomes of the three most commonly performed operations, i.e. adjustable gastric banding, the gastric bypass, and the biliopancreatic bypass with duodenal switch, it aims for perspective with the inclusion of abandoned and current investigational procedures, a review of the complications, and an emphasis on the appropriate selection of patients. POSITIONS: Ample evidence, including controlled randomized studies, now document that bariatric surgery produces durable weight loss exceeding 100 lb (46 kg), full and long-term remission of type 2 diabetes in over 80% with salutary effects on the other comorbidities as well with significant reductions in all-cause mortality. Although the severely obese present with serious surgical risks, bariatric surgery is performed safely with a 0.35% 90-d mortality in Centers of Excellence throughout the United States-similar to the complication rates after cholecystectomy.

CONCLUSIONS

Until better approaches become available, bariatric surgery is the therapy of choice for patients with severe obesity.