Efficacy of metabolic surgery on HbA1c decrease in type 2 diabetes mellitus patients with BMI <35 kg/m2--a review

Electrodiagnostic Testing and Nerve Ultrasound of the Carpal Tunnel in Patients with Type 2 Diabetes

In diabetic patients, controversies still exist about the validity of electrodiagnostic and nerve ultrasound diagnosis for carpal tunnel syndrome (CTS). We analyzed 69 patients with type 2 diabetes. Nerve conduction studies and peripheral nerve ultrasound of the median nerve over the carpal tunnel were performed. CTS symptoms were assessed using the Boston Carpal Tunnel Questionnaire. Polyneuropathy was assessed using the Neuropathy Symptom Score and the Neuropathy Disability Score. Although 19 patients reported predominantly mild CTS symptoms, 37 patients met the electrophysiological diagnosis criteria for CTS, and six patients were classified as severe or extremely severe. The sonographic cross-sectional area (CSA) of the median nerve at the wrist was larger than 12 mm² in 45 patients (65.2%), and the wrist-to-forearm-ratio was larger than 1.4 in 61 patients (88.4%). Receiver operating characteristic analysis showed that neither the distal motor latency, the median nerve CSA, nor the wrist-to-forearm-ratio could distinguish between patients with and without CTS symptoms. Diagnosis of CTS in diabetic patients should primarily be based upon typical clinical symptoms and signs. Results of electrodiagnostic testing and nerve ultrasound have to be interpreted with caution and additional factors have to be considered especially polyneuropathy, but also body mass index and hyperglycemia.

Twenty years' experience of laparoscopic 1-anastomosis gastric bypass: surgical risk and long-term results

BACKGROUND

Laparoscopic 1- (single-) anastomosis gastric bypass (OAGB) was developed as a simplified technique of Roux-en-Y gastric bypass (RYGB), but super long-term data are lacking.

OBJECTIVES

To evaluate the risks and long-term results of OAGB over a period of 20 years.

SETTING

Tertiary teaching hospital.

METHODS

A total of 2223 patients underwent OAGB from 2001 to 2020; the mean age was 35.3 ± 11.4 years (range, 14-71 yr), 70.2% were female, and the mean body mass index was 40.2 ± 11.9 kg/m². All data were kept in a prospective bariatric database. Patients were divided into 4 groups, based on the 5-year period in which their surgery was performed, and a retrospective analysis was conducted.

RESULTS

The means for operating time, intraoperative blood loss, and length of hospital stay after OAGB were 131.9 ± 40.1 minutes, 38.5 ± 30.7 mL, and 4.5 ± 4.0 days, respectively. There were 27 patients (1.2%) with 30-day postoperative major complications overall, but the group rate decreased to .4% in the last 5-year period. At postoperative years 5, 10, and 15, the percentages of total weight loss were 31.9%, 29.6%, and 29.5%, respectively, and the percentages of excess weight loss were 77.2%, 68.4%, and 65.5%, respectively. Among 739 patients (33.2%) with type 2 diabetes (T2D), the rates of complete remission (glycated hemoglobin < 60%) at 5, 10, and 15 years were 67.3%, 73.8%, and 66.7%, respectively. The weight loss and antimetabolic effects were similar in each 5-year period, but a significant malnutrition effect was observed. A total of 113 (5.1%) patients needed revision surgery at follow-up, due to malnutrition (n = 51), weight regain (n = 24), acid or bile reflux (n = 22), marginal ulcer (n = 8), ileus (n = 3), and other causes (n = 5). At 15 years, the overall revision rate was 11.9% (27/226), and 80% of the patients were very satisfied with their procedures.

CONCLUSION

Our results showed that OAGB is a safe and durable primary bariatric procedure, with sustained weight loss and a high resolution of T2D up to 20 years post surgery in Taiwan, although malnutrition is a major side effect.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT OF WEIGHT LOSS TRAJECTORY FOLLOWING RANDOMIZATION TO BARIATRIC SURGERY ON LONG-TERM DIABETES GLYCEMIC AND CARDIOMETABOLIC PARAMETERS

Objective: It is unclear whether acute weight loss or the chronic trajectory of weight loss after bariatric surgery is associated with long-term type 2 diabetes mellitus (T2DM) glycemic improvement. This ancillary study of the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial aimed to answer this question. Methods: In STAMPEDE, 150 patients with T2DM were randomized to bariatric surgery, and 96 had 5-year follow-up. Data post-Roux-en-Y gastric bypass (RYGB, n = 49) and sleeve gastrectomy (SG, n = 47) were analyzed. We defined percent weight loss in the first year as negative percent decrease from baseline weight to lowest weight in the first year. Percent weight regain was positive percent change from lowest weight in the first year to fifth year. Weight change was then correlated with cardiometabolic (CM) and glycemic outcomes at 5 years using Spearman rank correlations and multivariate analysis. Results: In both RYGB and SG, less weight loss in the first year positively correlated with higher 5-year glycated hemoglobin (HbA1c) (RYGB, β = +0.13; P<.001 and SG, β = 0.14; P<.001). In SG, greater weight regain from nadir positively correlated with higher HbA1c (β = 0.06; P = .02), but not in RYGB. Reduced first-year weight loss was also correlated with increased 5-year triglycerides (β = 1.81; P = .01), but not systolic blood pressure. Weight regain did not correlate with CM outcomes. Conclusion: Acute weight loss may be more important for T2DM glycemic control following both RYGB and SG as compared with weight regain. Clinicians should aim to assist patients with achieving maximal weight loss in the first year post-op to maximize long-term health of patients. Abbreviations: BMI = body mass index; HbA1c = glycated hemoglobin; RYGB = Roux-en-Y gastric bypass; SBP = systolic blood pressure; SG = sleeve gastrectomy; STAMPEDE = Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently; T2DM = type 2 diabetes mellitus; TG = triglyceride.

DIABETES REMISSION RATE IN DIFFERENT BMI GRADES FOLLOWING ROUX-EN-Y GASTRIC BYPASS

Background:

Type 2 diabetes mellitus has a high long-term remission rate after laparoscopic Roux-en-Y gastric bypass (LRYGB), but few studies have analyzed patients with BMI<35 kg/m².

Aim:

To compare glycemic control after LRYGB between BMI 30-35 kg/m² (intervention group or IG) and >35 kg/m² patients (control group or CG) and to evaluate weight loss, comorbidities and surgical morbidity.

Methods:

Sixty-six diabetic patients (30 in IG group and 36 in CG group) were submitted to LRYGB. Data collected annually after surgery were analyzed with generalized estimating equations.

Results:

Average follow-up was 4.3 years. There was no statistical difference between groups using complete remission American Diabetes Association criteria (OR 2.214, 95%CI 0.800-5.637, p=0.13). There was significant difference between groups using partial remission American Diabetes Association criteria (p=0.002), favouring the CG group (OR 6.392, 95%CI 1.922-21.260). The higher BMI group also had lower HbA1c levels (-0.77%, 95%CI -1.26 to -0.29, p=0.002). There were no significant differences in remission of hypertension, dyslipidemia and surgical morbidity, while weight was better controlled in the IG group.

Conclusion:

No differences were found in diabetes complete remission, although greater partial remission and the lower levels of glycated hemoglobin in the BMI >35 kg/m² group suggest a better response among more obese diabetic patients with LRYGB. In addition, both groups had important metabolic modifications at the expense of low morbidity.

Bariatric Surgery in Type 1 Diabetes Mellitus: A Systematic Review

Bariatric surgery is recognised as an effective treatment strategy for obese patients with type 2 diabetes mellitus. An increasing number of patients with type 1 diabetes mellitus also suffer with obesity and obesity-associated comorbidities but the role of bariatric and metabolic surgery in this group of patients is unclear. This systematic review investigates published English language scientific literature to understand the results of bariatric surgery in obese patients with type 1 diabetes mellitus. We found that these patients can experience significant weight loss and comorbidity resolution with bariatric surgery. Though most patients also see a decline in total insulin requirement, glycaemic control remains difficult. Most of the patients reported in literature have undergone gastric bypass but data is insufficient to recommend any particular procedure.

[Diabetes mellitus and cardiovascular risk: Working group recommendations of Diabetes and Cardiovascular Disease of the Spanish Society of Diabetes (SED, 2015)]

The present paper updates the Clinical Practice Recommendations for the management of cardiovascular risk factors (CVRF) in diabetes mellitus. This is a medical consensus agreed by an independent panel of experts from the Spanish Society of Diabetes (SED). Several consensuses have been proposed by scientific and medical Societies to achieve clinical goals. However, the risk score for general population may lack sensitivity for individual assessment or for particular groups at risk, such as diabetics. Traditional risk factors together with non-traditional factors are reviewed throughout this paper. Intervention strategies for managing CVRF in the diabetic patient are reviewed in detail: balanced food intake, weight reduction, physical exercise, smoking cessation, reduction in HbA1c, therapy for high blood pressure, obesity, lipid disorders, and platelet anti-aggregation. It is hoped that these guidelines can help clinicians in the decisions of their clinical activity. This regular update by the SED Cardiovascular Disease Group of the most relevant concepts, and of greater practical and realistic clinical interest, is presented in order to reduce CVR of diabetics.

Laparoscopic Adjustable Gastric Banding Revisions in Singapore: a 10-Year Experience

BACKGROUND

Bariatric surgery is increasingly being carried out and revisional procedures have also risen in concert. A review of the complications and revisions might elucidate technical and patient factors that influence the outcomes of bariatric surgeries in Asian patients. The objective of this study is to review the safety and efficacy of revisional bariatric surgery in a single center in Singapore over a 10-year period.

METHODS

The setting of this study is a single public hospital with a multidisciplinary bariatric service including a weight management center, specialized endocrinology services, and bariatric surgical team. Participants were selected for surgery based on body mass index (BMI) and comorbidities. All patients underwent primary laparoscopic adjustable gastric banding (LAGB). Patients were then analyzed according to the types of revisional surgeries. The primary outcome was the type of complications and revisional surgeries. Secondary outcomes include short-term excess weight loss and further complications.

RESULTS

A total of 365 patients were analyzed. 9.6% had a secondary procedure. In particular, two groups of complications required revisional surgery: failure of sustained weight loss and complications related to the LAGB insertion and use. Revisional surgeries had equivalent major complication rates (5.7%) compared to primary bariatric surgeries (6.8%). Revisional surgeries such as revisional LAGB (4.9 ± 9.8 kg), laparoscopic sleeve gastrectomy (LSG; 6.9 ± 21.0 kg), Roux-en-Y gastric bypass (RYGB; 4.6 ± 13.0 kg), and bilio-pancreatic diversion (BPD; 3.5 ± 6.3 kg) had modest weight loss compared to primary weight loss (12.7 ± 9.5 kg). Primary LAGB had a greater percentage excess weight loss in the first and second years post-surgery compared to revisional surgeries. There was one mortality post-primary surgery and no post-revisional surgical mortalities.

CONCLUSIONS

Revisional bariatric surgery for complications related to the primary surgery is safe but had reduced excess weight loss compared to the initial surgery.

History and current status of bariatric and metabolic surgeries in East Asia

Morbid obesity and obesity-related comorbidities are major public health problems around the world, including in East Asia. Although Asian populations have been shown to have an elevated risk of type 2 diabetes mellitus, hypertension, and hyperlipidemia at a relatively lower BMI than Western populations, the Asian perspective on bariatric and metabolic surgeries has not been actively discussed until recently. Bariatric surgery in East Asia has undergone a paradigm shift since the first laparoscopic vertical bariatric surgery was performed in Taiwan in 1998, which was subsequently followed by the introduction of laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, and mini-gastric bypass. Since 2006, use of laparoscopic sleeve gastrectomy has remarkably increased because of its ease, speed, and safety. With regard to metabolic surgery, a randomized controlled trial in Taiwan demonstrated that laparoscopic Roux-en-Y gastric bypass is more effective than laparoscopic sleeve gastrectomy for surgical treatment of poorly controlled type 2 diabetes mellitus and metabolic syndrome. In this article, we describe the history of bariatric procedures, revision surgeries, weight-loss effect, and metabolic surgeries in Asian populations, and we also discuss minimally invasive bariatric surgery with some important citations.

Gap Between Evidence and Patient Access: Policy Implications for Bariatric and Metabolic Surgery in the Treatment of Obesity and its Complications

Despite consistently supportive evidence of clinical effectiveness and economic advantages compared with currently available non-surgical obesity treatments, patient access to bariatric and metabolic surgery (BMS) is impeded. To address this gap and better understand the relationship between value and access, the objectives of this study were twofold: (i) identify the multidimensional barriers to adoption of BMS created by clinical guidelines, public policies, and health technology assessments; and, most importantly, (ii) develop recommendations for stakeholders to improve patient access to BMS. Updated public policies focused on treatment and clinical guidelines that reflect the demonstrated advantages of BMS, patient education on safety and effectiveness, updated reimbursement policies, and additional data on long-term BMS effectiveness are needed to improve patient access.