Predictive factors of type 2 diabetes mellitus remission following bariatric surgery: a meta-analysis

Discontinuation of blood pressure-lowering, glucose-lowering, and lipid-lowering medications after bariatric surgery in patients with morbid obesity: a nationwide cohort study in South Korea

BACKGROUND

Limited evidence exists on the patterns of medication use for hypertension, diabetes mellitus (DM), and dyslipidemia after bariatric surgery among Asian patients.

OBJECTIVES

To investigate the patterns in the use of blood pressure-lowering, glucose-lowering, and lipid-lowering medications following BS in Korean patients with morbid obesity.

SETTING

This study is a retrospective cohort study using the Health Insurance Review and Assignment claims database of South Korea (from 2019 to 2021).

METHODS

We included patients who underwent BS between 2019 and 2020 in South Korea. We evaluated the treatment patterns of blood pressure-lowering, glucose-lowering, and lipid-lowering medications at 3-month intervals for 1-year following BS, including medication use, individual medication classes, and the number of medications prescribed. Furthermore, we estimated remission rates for each disorder based on patient characteristics by defining patients who discontinued their medications for at least 2 consecutive quarters as remission.

RESULTS

A total of 3810 patients were included in this study. For 1-year following BS, a marked decrease in the number of patients using blood pressure-lowering, glucose-lowering, and lipid-lowering medications was observed. The most remarkable decrease occurred in glucose-lowering medications, which decreased by approximately -75.1% compared with that at baseline. This tendency was consistently observed when analyzing both the number of medications prescribed and the specific medication classes. Regarding remission rates, patients who were female, younger, and received the biliopancreatic diversion-duodenal switch as their BS showed a relatively higher incidence of remission than other groups.

CONCLUSIONS

BS was associated with a decrease in the use of medications for hypertension, diabetes mellitus (DM), and dyslipidemia.

Contemporary Clinical Perspectives on Targeting Remission of Type 2 Diabetes

It has long been known that some patients with type 2 diabetes (T2DM) can experience sustained metabolic improvement to near-normal levels of glycemia either spontaneously or after medical intervention. Now recognized as remission of diabetes, this intriguing state is currently more feasible than ever before due to profound advances in metabolic surgery, pharmacologic therapy, and regimens of lifestyle modification. This enhanced capacity to induce remission has revealed new pathophysiologic insights, including the presence of a reversible component of the pancreatic beta-cell dysfunction that otherwise drives the chronic progressive nature of T2DM. In doing so, it has changed the therapeutic landscape by offering new potential management objectives and considerations for patients and providers. However, the excitement around these developments must also be tempered by the sobering realities of our current understanding of remission, including the recognition that this condition may not be permanent (resulting in glycemic relapse over time) and that beta-cell function may not be normalized in the setting of remission. These limitations highlight both the many gaps in our current understanding of remission and the caution with which clinical discussions must be handled for clear patient-directed communication of the pros and cons of targeting this outcome in practice. In this mini-review, we consider this rapidly growing literature, including its implications and its limitations, and thereby seek to provide objective balanced perspectives on targeting remission of T2DM in current clinical care.

Cardiometabolic Improvements After Metabolic Surgery and Related Presurgery Factors

Context

Metabolic surgery remains the most effective and durable treatment for severe obesity and related metabolic diseases.

Objective

We examined cardiometabolic improvements after metabolic surgery and associated presurgery demographic and clinical factors in a large multiracial cohort.

Methods

Included were 7804 patients (20-79 years) undergoing first-time metabolic surgery at Vanderbilt University Medical Center from 1999 to 2022. Pre- and 1-year postsurgery cardiometabolic profiles were extracted from medical records, including body mass index (BMI), blood pressure, blood lipids, glucose, and hemoglobin A1c. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk was estimated per American College of Cardiology/American Heart Association equations. Pre- to postsurgery cardiometabolic profiles were compared by paired t-test, and associated factors were identified by multivariable linear and logistic regression.

Results

Among 7804 patients, most were women and White, while 1618 were men and 1271 were Black; median age and BMI were 45 years [interquartile range (IQR): 37-53] and 46.4 kg/m2 (IQR: 42.1-52.4). At 1-year postsurgery, patients showed significant decreases in systolic blood pressure (10.5 [95% confidence interval: 10.1, 10.9] mmHg), total cholesterol (13.5 [10.3, 16.7] mg/dL), glucose (13.6 [12.9, 14.4] mg/dL), hemoglobin A1c (1.13% [1.06, 1.20]), and 10-year ASCVD risk (absolute reduction: 1.58% [1.22, 1.94]; relative reduction: 34.4% [29.4, 39.3]); all P < .0001. Older, male, or Black patients showed less reduction in 10-year ASCVD risk and lower odds of diabetes/hypertension/dyslipidemia remission than younger, female, or White patients. Patients with a history of diabetes, hypertension, dyslipidemia, or cardiovascular disease showed less cardiometabolic improvements than those without. Results were similar with or without further adjusting for weight loss and largely sustained at 2-year postsurgery.

Conclusion

Metabolic surgery results in significant cardiometabolic improvements, particularly among younger, female, or White patients and those without comorbidities.

Comparison of various prediction models in the effect of laparoscopic sleeve gastrectomy on type 2 diabetes mellitus in the Chinese population 5 years after surgery

BACKGROUND

The effect of bariatric surgery on type 2 diabetes mellitus (T2DM) control can be assessed based on predictive models of T2DM remission. Various models have been externally verified internationally. However, long-term validated results after laparoscopic sleeve gastrectomy (LSG) surgery are lacking. The best model for the Chinese population is also unknown.

METHODS

We retrospectively analyzed Chinese population data 5 years after LSG at Beijing Shijitan Hospital in China between March 2009 and December 2016. The independent t -test, Mann-Whitney U test, and chi-squared test were used to compare characteristics between T2DM remission and non-remission groups. We evaluated the predictive efficacy of each model for long-term T2DM remission after LSG by calculating the area under the curve (AUC), sensitivity, specificity, Youden index, positive predictive value (PPV), negative predictive value (NPV), and predicted-to-observed ratio, and performed calibration using Hosmer-Lemeshow test for 11 prediction models.

RESULTS

We enrolled 108 patients, including 44 (40.7%) men, with a mean age of 35.5 years. The mean body mass index was 40.3 ± 9.1 kg/m 2 , the percentage of excess weight loss (%EWL) was (75.9 ± 30.4)%, and the percentage of total weight loss (%TWL) was (29.1± 10.6)%. The mean glycated hemoglobin A1c (HbA1c) level was (7.3 ± 1.8)% preoperatively and decreased to (5.9 ± 1.0)% 5 years after LSG. The 5-year postoperative complete and partial remission rates of T2DM were 50.9% [55/108] and 27.8% [30/108], respectively. Six models, i.e., "ABCD", individualized metabolic surgery (IMS), advanced-DiaRem, DiaBetter, Dixon et al' s regression model, and Panunzi et al 's regression model, showed a good discrimination ability (all AUC >0.8). The "ABCD" (sensitivity, 74%; specificity, 80%; AUC, 0.82 [95% confidence interval [CI]: 0.74-0.89]), IMS (sensitivity, 78%; specificity, 84%; AUC, 0.82 [95% CI: 0.73-0.89]), and Panunzi et al' s regression models (sensitivity, 78%; specificity, 91%; AUC, 0.86 [95% CI: 0.78-0.92]) showed good discernibility. In the Hosmer-Lemeshow goodness-of-fit test, except for DiaRem ( P <0.01), DiaBetter ( P <0.01), Hayes et al ( P = 0.03), Park et al ( P = 0.02), and Ramos-Levi et al' s ( P <0.01) models, all models had a satifactory fit results ( P >0.05). The P values of calibration results of the "ABCD" and IMS were 0.07 and 0.14, respectively. The predicted-to-observed ratios of the "ABCD" and IMS were 0.87 and 0.89, respectively.

CONCLUSION

The prediction model IMS was recommended for clinical use because of excellent predictive performance, good statistical test results, and simple and practical design features.

Transcriptome Changes and Metabolic Outcomes After Bariatric Surgery in Adults With Obesity and Type 2 Diabetes

Context

Bariatric surgery has been shown to be effective in inducing complete remission of type 2 diabetes in adults with obesity. However, its efficacy in achieving complete diabetes remission remains variable and difficult to predict before surgery.

Objective

We aimed to characterize bariatric surgery-induced transcriptome changes associated with diabetes remission and the predictive role of the baseline transcriptome.

Methods

We performed a whole-genome microarray in peripheral mononuclear cells at baseline (before surgery) and 2 and 12 months after bariatric surgery in a prospective cohort of 26 adults with obesity and type 2 diabetes. We applied machine learning to the baseline transcriptome to identify genes that predict metabolic outcomes. We validated the microarray expression profile using a real-time polymerase chain reaction.

Results

Sixteen patients entered diabetes remission at 12 months and 10 did not. The gene-expression analysis showed similarities and differences between responders and nonresponders. The difference included the expression of critical genes (SKT4, SIRT1, and TNF superfamily), metabolic and signaling pathways (Hippo, Sirtuin, ARE-mediated messenger RNA degradation, MSP-RON, and Huntington), and predicted biological functions (β-cell growth and proliferation, insulin and glucose metabolism, energy balance, inflammation, and neurodegeneration). Modeling the baseline transcriptome identified 10 genes that could hypothetically predict the metabolic outcome before bariatric surgery.

Conclusion

The changes in the transcriptome after bariatric surgery distinguish patients in whom diabetes enters complete remission from those who do not. The baseline transcriptome can contribute to the prediction of bariatric surgery-induced diabetes remission preoperatively.

Comparison of various prediction models in the effect of Roux-en-Y gastric bypass on type 2 diabetes in the Chinese population 5 years after surgery

BACKGROUND

Various prediction models of type 2 diabetes (T2D) remission have been externally verified internationally. However, long-term validated results after Roux-en-Y gastric bypass (RYGB) surgery are lacking. The best model for the Chinese population is also unknown.

OBJECTIVES

To evaluate the prediction effect of various prediction models on the long-term diabetes remission after RYGB in the Chinese population and to provide reference for clinical use.

SETTING

A retrospective clinical study at a university hospital.

METHODS

We retrospectively analyzed Chinese population data 5 years after RYGB and externally validated 11 predictive models to evaluate the predictive effect of each model on long-term T2D remission after RYGB.

RESULTS

We enrolled 84 patients. The mean body mass index was 41 kg/m2, and the percentage of excess weight loss (%EWL) was 72.3%. The mean glycated hemoglobin level was 8.4% preoperatively and decreased to 5.9% after 5 years. The 5-year postoperative complete and partial remission rates of T2D were 31% and 70.2%, respectively. The ABCD scoring model (sensitivity, 84%; specificity, 76%; area under the curve [AUC], .866) and the Panuzi et al. [34] study (sensitivity, 84%; specificity, 81%; AUC, .842) showed excellent results. In the Hosmer-Lemeshow goodness-of-fit test, calibration values for ABCD and Panuzi et al. [34] were .14 and .21, respectively. The predicted-to-observed ratios of ABCD and Panuzi et al. [34] were .83 and .88, respectively.

CONCLUSIONS

T2D was relieved to varying degrees 5 years after RYGB in patients with obesity. The prediction models in ABCD and the Panuzi et al. [34] studies showed the best prediction effects. ABCD was recommended for clinical use because of excellent predictive performance, good statistical test results, and simple and practical design features.

Diabetic Markers, Five Years after Bariatric Surgery

Background: Bariatric surgery delivers substantial weight loss for obese patients with comorbidities like diabetes mellitus. We aimed to investigate the impacts of bariatric surgery on diabetic markers after 5 years of follow-up. Methods: This is a retrospective study on patients with diabetes and a history of bariatric surgery between 2016-2017. The diabetic markers before and 5 years following surgery, including a lipid profile, glucose level, and the required antidiabetic medications, were evaluated. Results: 34 consecutive patients were included, 30 (88.2%) women, with a mean age of 52.71±8.53 years. The majority (65%) of surgeries were Roux-en-Y gastric bypass (RYGB), and the remaining were one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG). The serum levels of diabetic markers reduced during follow-up (P=0.001), except for high-density lipoprotein levels and serum total cholesterol, which increased (P=0.011, P=0.838). Low-density lipoprotein levels reduced, but it was insignificant (P=0.194). Surgery types had affected the changes of diabetic markers (P>0.05). Demand for oral medication was reduced significantly, but insulin injection reduction was not significant (P=0.006 and P=0.099, respectively). Conclusion: Our study showed favorable bariatric surgery results on patients with diabetes in long-term follow-up. However, dyslipidemia is still a concern.

Use of Continuous Glucose Monitoring in Patients Following Bariatric Surgery: A Scoping Review

The objective of this scoping review was to summarize the emerging literature on the use of continuous glucose monitoring (CGM) in post-bariatric surgery patients, with a focus on its features (e.g., device, mode, and accuracy), as well as purposes and outcomes of utilization. Three databases (PubMed, EMBASE, and Web of Science) were searched to obtain relevant studies. Results suggested that most studies used CGM for 3-7 days under blinded mode. Accuracy data were available in only one study, which reported a mean absolute relative difference of 21.7% for Freestyle Libre. The primary applications of CGM were for elucidating glucose patterns and assessing glycemic treatment outcomes. No study has tested the effect of CGM as an intervention strategy to enhance glucose control.

Predictors of T2DM Remission after Bariatric Surgery in Patients with a BMI < 35 kg/m2: a Meta-Analysis

PURPOSE

Although a few studies have reported the predictors of postoperative diabetes remission in patients with body mass index (BMI) < 35 kg/m2, the conclusions are still inconsistent. This meta-analysis aimed to evaluate the preoperative clinical factors of type 2 diabetes mellitus (T2DM) remission after bariatric surgery.

MATERIALS AND METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched until April 2022. The Newcastle-Ottawa Scale was used for quality assessment. Statistical heterogeneity was assessed with the I2 statistic, followed by subgroup and sensitivity analyses.

RESULTS

16 studies involving 932 patients were selected. T2DM remission was negatively correlated with age, duration, insulin use, fasting plasma glucose, fasting insulin, and glycosylated hemoglobin levels. While BMI, body weight, waist circumference, and C-peptide levels were positive predictors of T2DM remission in patients with a BMI < 35 kg/m2. However, there was no significant association between gender, oral hypoglycemic agent, homeostasis model assessment, high-density lipoprotein, low-density lipoprotein, total cholesterol, triglycerides, systolic blood pressure, diastolic blood pressure, and remission rate.

CONCLUSION

Patients with younger age, short diabetes duration, more obesity, better glucose control, and better β cell function were more likely to achieve T2DM remission in patients with a BMI < 35 kg/m2 after bariatric surgery.

Baseline determinants of remission of type 2 diabetes in response to short-term insulin-based therapy: The pivotal role of beta-cell function

AIM

To identify baseline determinants of diabetes remission in response to short-term insulin-based therapy.

METHODS

In this study, adult patients with type 2 diabetes (T2D) of less than 7 years duration were randomized to 8 weeks of treatment with (a) insulin glargine, (b) glargine + thrice-daily lispro, or (c) glargine + twice-daily exenatide, followed by 12 weeks of washout that enabled assessment of remission (defined as HbA1c < 6.5% after ≥ 3 months without glucose-lowering therapy). At baseline, 8 weeks and washout, beta-cell function was assessed with four measures: Insulin Secretion-Sensitivity Index-2 (ISSI-2), insulinogenic index/Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), ΔC-peptide_0-120 /Δglucose_0-120  × Matsuda and Δinsulin secretion rate (ISR)_0-120 /Δgluc_0-120  × Matsuda.

RESULTS

Diabetes remission was achieved in 31 of 90 participants (34.4%). Compared with their peers, those who went on to remission had lower HbA1c (P < .001) and better beta-cell function at baseline (all four measures P ≤ .01). The non-remission and remission groups did not otherwise differ in baseline insulin sensitivity/resistance (Matsuda, HOMA-IR), body mass index, duration of diabetes, pretrial diabetes medications or allocated insulin-based therapy during the trial. On logistic regression analyses, each baseline measure of beta-cell function emerged as a significant predictor of remission (log ISSI-2: adjusted OR 4.41 [95% CI: 1.71-11.34]; log insulinogenic index/HOMA-IR: 2.21 [1.26-3.89]; log ΔC-peptide_0-120 /Δglucose_0-120  × Matsuda: 1.62 [1.00-2.64]; log ΔISR_0-120 /Δgluc_0-120  × Matsuda: 1.87 [1.09-3.23]). Similarly, higher baseline ISSI-2 tertile predicted longer time to glycaemic relapse after cessation of the insulin-based therapy (log-rank P = .029).

CONCLUSION

Beta-cell function is the dominant baseline pathophysiological determinant of the likelihood of achieving remission of diabetes in response to short-term insulin-based therapy.

Accuracy of prediction models for long-term type 2 diabetes remission after gastric bypass

AIM

To evaluate the accuracy of DiaBetter, DiaRem, Ad-DiaRem and 5y-Ad-DiaRem scores' at predicting T2D remission 10 or more years after surgery.

METHODS

Patients with obesity and T2D (n = 126) submitted to RYGB with 10 or more years of follow-up. It was a unicentric trial. Pre-operative anthropometric and clinical data was retrieved to calculate DiaRem, DiaBetter, Ad-DiaRem and 5y-Ad-DiaRem scores, while a hospital visit was conducted to assess current diabetes status. The area under the receiver operating characteristic (AUROC) curve was calculated as estimate of the scores' accuracy to predict long-term T2D remission.

RESULTS

Among the entire cohort (n = 126), 70 subjects (55.6%) achieved and maintained T2D remission 10 or more years after RYGB. The 5y-Ad-DiaRem score was the one that depicted the highest discriminative power (AUROC = 0.838) to predict long-term T2D remission when compared to DiaBetter (AUROC = 0.735), DiaRem (AUROC = 0.721) and Ad-DiaRem (AUROC = 0.720).

CONCLUSION

The score with highest accuracy to predict long-term T2D remission after RYGB surgery was the 5y-Ad-DiaRem. Yet, the available scores accuracy to predict T2D remission in the long term is still suboptimal, highlighting the unmet need for a better scoring system.

Scores for Predicting Diabetes Remission in Bariatric Surgery: a Systematic Review and Meta-analysis

This systematic review aims to compare the accuracy of pre-existent scores predicting diabetes remission after bariatric and metabolic surgery. Among the scores, DiaBetter presented the largest area under the curve (AUC) (0.87; 95% CI, 0.84-0.9). Ad-DiaRem had the lowest AUC (0.79; 95% CI, 0.76-0.83). Ad-DiaRem showed the highest sensitivity (91%; 95% CI, 86-96%), with a specificity of 71.23% (95% CI 50.43 to 92.06%). IMS showed a sensitivity of 59% (95% CI, 20-90%), with the highest specificity (86%; 95% CI, 69-94%). Clinicians should associate the findings of the present review with patients' individual characteristics to help predict diabetes remission and evaluate the probability of the patient benefit from surgery.

Prehabilitation of overweight and obese patients with dysglycemia awaiting bariatric surgery: Predicting the success of obesity treatment

Bariatric surgery offers the best health results in overweight and obese patients but is not a risk and/or complication-free treatment. In cases with additional hyperglycemia, the burden of surgery can be even higher and alter both short-term and long-term outcomes. Although bariatric surgery offers glycemic improvements and in the case of early onset diabetes disease remission, weight loss results are lower than for obese patients without diabetes. Different multimodal programs, usually including interventions related to patients' performance, nutritional and psychological status as well as currently available pharmacotherapy before the surgery itself might considerably improve the immediate and late postoperative course. However, there are still no clear guidelines addressing the prehabilitation of obese patients with dysglycemia undergoing bariatric surgery and therefore no unique protocols to improve patients' health. In this minireview, we summarize the current knowledge on prehabilitation before bariatric surgery procedures in patients with obesity and dysglycemia.

Data assimilation on mechanistic models of glucose metabolism predicts glycemic states in adolescents following bariatric surgery

Type 2 diabetes mellitus is a complex and under-treated disorder closely intertwined with obesity. Adolescents with severe obesity and type 2 diabetes have a more aggressive disease compared to adults, with a rapid decline in pancreatic β cell function and increased incidence of comorbidities. Given the relative paucity of pharmacotherapies, bariatric surgery has become increasingly used as a therapeutic option. However, subsets of this population have sub-optimal outcomes with either inadequate weight loss or little improvement in disease. Predicting which patients will benefit from surgery is a difficult task and detailed physiological characteristics of patients who do not respond to treatment are generally unknown. Identifying physiological predictors of surgical response therefore has the potential to reveal both novel phenotypes of disease as well as therapeutic targets. We leverage data assimilation paired with mechanistic models of glucose metabolism to estimate pre-operative physiological states of bariatric surgery patients, thereby identifying latent phenotypes of impaired glucose metabolism. Specifically, maximal insulin secretion capacity, σ, and insulin sensitivity, SI, differentiate aberrations in glucose metabolism underlying an individual's disease. Using multivariable logistic regression, we combine clinical data with data assimilation to predict post-operative glycemic outcomes at 12 months. Models using data assimilation sans insulin had comparable performance to models using oral glucose tolerance test glucose and insulin. Our best performing models used data assimilation and had an area under the receiver operating characteristic curve of 0.77 (95% confidence interval 0.7665, 0.7734) and mean average precision of 0.6258 (0.6206, 0.6311). We show that data assimilation extracts knowledge from mechanistic models of glucose metabolism to infer future glycemic states from limited clinical data. This method can provide a pathway to predict long-term, post-surgical glycemic states by estimating the contributions of insulin resistance and limitations of insulin secretion to pre-operative glucose metabolism.

Type 2 diabetes remission after Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and one anastomosis gastric bypass (OAGB): results of the longitudinal assessment of bariatric surgery study

BACKGROUND

Several studies on various bariatric surgeries involving patients with type 2 diabetes mellitus (T2DM) showed an overall rate of remission of hyperglycemia. However, there is little known about predictive factors on remission after different types of surgeries. The aim of this study was to identify the T2DM remission rate and to determine the effects of preoperative factors characteristics of remission of type 2 diabetes in Iran.

METHODS

We conducted a retrospective analysis of 1351 patients with T2DM operated by three different types of surgeries (Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and One Anastomosis Gastric Bypass (OAGB)). Diabetes remission was defined according to the American Diabetes Association (ADA) criteria. Binary logistic regression analyses were employed.

RESULTS

A total of 1351 patients, 675 patients (50.0%) undergoing OAGB, 475 (35.2%) RYGB, and 201 (14.9%) SG. 80.6%, 84.2% of OAGB, 81.7%, 82.6% of RYGB, and 77.1%, 81.5% of SG participants were in T2DM remission after 1 and 3 years, respectively. 1- and 3-year remission were associated with preoperative age, duration of T2DM, FBS and HbA1c, BMI, insulin therapy, and a family history of obesity (p < 0.05).

CONCLUSION

The remission of T2DM after RYGB, SG, and OAGB surgery is dependent on various preoperative factors. Patients with younger age, shorter duration of T2DM, lower preoperative HbA1c and FBS, higher BMI, who were not on insulin therapy, and not having a family history of obesity were the best candidates to achieve a prolonged diabetes remission.

Nonalcoholic fatty liver disease in relation to the remission and progression along the glycemic continuum

BACKGROUND

The study aimed to explore the associations of nonalcoholic fatty liver disease (NAFLD) with the remission and progression along the glycemic continuum.

METHODS

This prospective cohort study was performed among the general population in 2010-2015. NAFLD was defined as ultrasound-detected hepatic steatosis with absence of excessive alcohol consumption and other hepatic diseases. Remission of type 2 diabetes referred to glycated hemoglobin <6.5% without hypoglycemic agents for ≥3 months. Prediabetes remission referred to normalization of blood glucose. Multivariable logistic analysis was applied to identify the risk of glycemic metabolic transition.

RESULTS

During a median follow-up of 4.3 years, participants with NAFLD had a significantly higher risk of progressing from normal glucose tolerance to diabetes (3.36 [1.60-7.07]) and lower likelihood of diabetes remission (0.48 [0.30-0.78]). Associations in participants with overweight or obesity and higher probability of hepatic fibrosis remained consistent. Results related to the effect of NAFLD on the specific glucose parameters were generally in line with the changes of glycemic status. NAFLD improvement decreased the risk of prediabetes progressing to diabetes (0.50 [0.32-0.80]) and increased the probability of prediabetes remission (2.67 [1.49-4.79]). NAFLD tended to show the most significant association with glycemic progression and decreased the likelihood in remission of prediabetes and diabetes.

CONCLUSIONS

Presence of NAFLD increased risk of glycemic progression and decreased likelihood of remission. NAFLD improvement mitigated glycemic deterioration, whereas NAFLD progression impeded the chance of remission. The results emphasized joint management of NAFLD and diabetes and further focused on liver-specific subgroups of diabetes to tailor early intervention.

East Asian perspectives in metabolic and bariatric surgery

The prevalence of diabetes and obesity continues to rise in East Asia. As the risk of diabetes increases at a lower body mass index (BMI) in East Asians than in Europeans, the threshold of BMI values for metabolic and bariatric surgery (MBS) is lower in East Asians. MBS is considered upon reaching a BMI of 27.5 kg/m2 and is recommended at a BMI of ≥ 32.5 kg/m2 , depending on the status of glucose homeostasis. The most commonly performed MBS in East Asia is sleeve gastrectomy, followed by Roux-en-Y gastric bypass (RYGB). Because the incidence of gastric cancer is higher in East Asia than in other regions, concerns regarding surveillance for gastric cancer might be related to a preference for sleeve gastrectomy over RYGB in this region. Even though there is a paucity of data on direct comparisons of the efficacy of MBS among different ethnic groups, the degree of weight reduction in East Asians is not inferior to other ethnic groups. Moreover, studies suggest that the diabetes remission rate in East Asians seemed to be higher than in other ethnic groups. Future studies involving multiethnic groups are necessary to identify possible ethnic differences in diabetes remission and to determine the appropriate BMI threshold for MBS according to ethnicity.

Lipid Accumulation Product Predicts Diabetes Remission After Bariatric Surgery in Chinese Patients with BMI < 35 kg/m2: a Multicenter Cohort Study

PURPOSE

To evaluate whether preoperative visceral fat-related indexes, such as visceral adiposity index (VAI), lipid accumulation product (LAP), Chinese visceral adiposity index (CVAI), and metabolic score for visceral fat (METS-VF), are useful for predicting diabetes remission in Chinese patients with a BMI < 35 kg/m² after bariatric surgery.

MATERIALS AND METHODS

A retrospective, multicenter cohort study enrolled 177 patients. Binary logistic regression and receiver operating characteristic (ROC) curves were used to identify predictors and clinically useful cutoff values, respectively. The correlation between the visceral fat-related index and body fat percentage was assessed.

RESULTS

Complete remission of type 2 diabetes (T2DM) was observed in 66 patients (37.29%) 1 year after surgery. The VAI, LAP, CVAI, and METS-VF showed downward trends postsurgery. Patients with complete remission had a significantly shorter duration of diabetes and higher CVAI, VAI, LAP, and BMI values than those without complete remission. Binary logistic regression and ROC analysis confirmed that diabetes duration and LAP can predict diabetes remission after bariatric surgery, and a LAP of 67.725 is a useful threshold for predicting surgical efficacy. LAP was significantly positively correlated with VAT/total (%) (p < 0.05).

CONCLUSION

Preoperative LAP is a feasible tool for predicting T2DM remission in patients with a BMI < 35 kg/m² after bariatric surgery, and a LAP of 67.725 is a useful threshold for predicting surgical outcomes. LAP was significantly positively correlated with VAT content.

Impact of sleeve gastrectomy on abnormalities in carbohydrate tolerance in obese adult

INTRODUCTION

Facing the repeated failures of the medical management of obesity, bariatric surgery offers a promising therapeutic option in terms of achieving weight loss and metabolic benefits.

AIM

To evaluate the impact of sleeve gastrectomy on the carbohydrate profile of a group of obese subjects.

METHODS

It is a prospective study including 40 obese patients (7 Men and 33 Women) who underwent sleeve gastrectomy between 2016 and 2018. Clinical and biological parameters were collected before the intervention, at six months and one year after. Insulin resistance was defined by a HOMA-IR index ≥2.4. Remission of diabetes was determined using the American Society for Metabolic and Bariatric Surgery's (ASMBS) criteria.

RESULTS

The mean patients' age was 34.65 ± 8.17 years. The mean body mass index (BMI) was 50.23 ± 8.3 kg/m². One year after sleeve gastrectomy, the frequency of insulin resistance, decreased from 89% to 4% (p<0.05). The evolution of carbohydrate tolerance abnormalities was marked by the diabetes and prediabetes remission in 75% and 100% of cases, respectively. The mean excess weight loss was 55.8% at 12 months.

CONCLUSION

These results have expanded our knowledge of the short-term sleeve gastrectomy's effectiveness on the carbohydrate profile of obese subjects. However, it would be interesting to check the durability of this metabolic benefit in the medium and long term.

Bariatric surgery for the management of type 2 diabetes mellitus-current trends and challenges: a review article

Obesity has become an epidemic and has emerged as a serious ailment of global concern. Longstanding obesity may lead to several complications, including type 2 diabetes mellitus (T2DM). Considering the role of the gastrointestinal tract (GIT) in glycemic control, altering it would be relevant to the T2DM management algorithm. Bariatric surgery is a well-known surgical procedure that alters the GIT for managing T2DM among moderate to severely obese patients. T2DM remissions (adequate glycemic control without any other antidiabetic drugs) among the post-bariatric patients are due to weight loss related and weight loss unrelated pathophysiological mechanisms, including caloric intake restriction, increased insulin secretion, sensitivity, and malabsorption. Evidence suggests that bariatric surgeries among T2DM patients improved micro and macrovascular complications. Bariatric surgical procedures have more advantages of post-operative weight loss and glycemic control in biliopancreatic diversions than other available bariatric surgical procedures. Several concerns raised on the short and long-term risks associated with the bariatric surgery were nutritional deficiencies, psychological issues, GIT ulcers, and survival rates. Data related to follow-up of complications related to the above-stated risk are still elusive. According to some of the recently published studies, relapse of T2DM after remission is a worrying phenomenon among post-bariatric surgery patients, requiring more clinical trials and long-term follow-up on the relapsed patients. The effectiveness of reoperation among the relapsed patients also needs to be evaluated. Other unresolved issues related to bariatric surgery are patient compliance, cost-effectiveness, quality of life among post-bariatric patients, and the effectiveness of the post-operative holistic approach to avoid relapse. Future studies, especially randomized controlled trials, are recommended to resolve the existing controversies associated with bariatric surgery.

Lipocalin, Resistin and Gut Microbiota-Derived Propionate Could Be Used to Predict Metabolic Bariatric Surgery Selected Outcomes

Many patients with clinically severe obesity (CSO) need to undergo bariatric surgery, with possible side effects, so individualized predictive methods are required. Adipocytokines and gut/intestinal microbiota-derived metabolites could be predictive biomarkers of metabolic success post- surgery, but the knowledge in this field is undefined. The objective of this work was to determine whether adipocytokines and microbiota-derived metabolites can be used to predict the metabolic improvement post- surgery in women with CSO. We analyzed circulating levels of some cytokines and some microbiota-derived metabolites at baseline and 12 months post-surgery from 44 women with CSO and 21 women with normal weight. Results showed that glucose, insulin, glycosylated hemoglobin A1c (HbA1c), low-density lipoprotein (LDL-C), and triglycerides levels were decreased post-surgery, while high density lipoprotein increased. Twelve months later, leptin, resistin, lipocalin, PAI-1, TNF-α, and IL-1β levels were lower than baseline, meanwhile adiponectin, IL-8, and IL-10 levels were increased. Moreover, baseline lipocalin levels were associated with HbA1c reduction post-surgery; meanwhile baseline resistin was related to postoperative HOMA2 (insulin resistance) and baseline propionate was associated with LDL-C decrease. To conclude, the detection of lipocalin, resistin, and propionate levels may be used to predict the metabolic success following bariatric surgery, although new knowledge is needed.

Evaluation of the Effects of Bariatric Surgery in Terms of Weight Loss and Diabetes Remission in the Indian Population

<b><i>Objectives:</i></b> The growing prevalence of obesity rates worldwide is associated with an upsurge in its comorbidities, particularly type 2 diabetes mellitus (T2DM). Bariatric surgery is a proven treatment modality for producing sustained weight loss and resolution of associated T2DM providing marked improvement in quality of life with rapid recovery. This study aims to investigate the effects of laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and mini-gastric bypass (MGB) on obese patients suffering from T2DM in the Indian population and their long-term association with regard to diabetes remission, resolution of comorbidities, and percentage EWL. <b><i>Methods:</i></b> Retrospective data of obese patients with T2DM (preoperative BMI 45.37 ± 8.1) who underwent bariatric surgery (RYGB, LSG, and MGB) were analyzed in this study over a period of 9 years. The mean follow-up period was 2.2 years. Following surgery, the clinical outcome on BMI, resolution of percentage weight loss, and T2DM were studied. The predictive factors of diabetic remission after surgery were determined. Student’s <i>t</i> test and ANOVA and McNemar’s test were applied. <b><i>Results:</i></b> Out of a total of 274 patients, complete remission of T2DM was achieved in 52.9% (<i>n</i> = 145) with mean fasting blood glucose and glycated hemoglobin values being 6.1 ± 0.769 (<i>p</i> = 0.00) at 1 year after surgery. The independent predictive factors of remission were age, gender, BMI, preoperative comorbidities, and % EWL. Gender had no correlation with the chance of achieving disease remission. <b><i>Conclusion:</i></b> Based on our results, bariatric surgery proves to be a successful treatment option resulting in sustained weight loss in obese patients suffering from T2DM. It is found to be beneficial for the long-term resolution of T2DM and improving comorbidities such as hypertension and dyslipidemia. The outcome of the different surgical methods is found to be similar for all patients irrespective of the independent predictors of complete remission.

Sensitivity of DiaRem Scoring System in Predicting Type Two Diabetes Mellitus Resolution After Bariatric Surgery in Qassim Region

INTRODUCTION

Type two diabetes mellitus (T2DM) remission has been observed as an additional benefit of bariatric surgery for morbidly obese diabetic patients. There are many scoring systems for identifying factors that predict diabetes remission; however, there is as yet no universally applicable scoring system.

AIM

This study aims to test the sensitivity of the DiaRem scoring system for predicting the resolution of T2DM in morbidly obese patients who underwent bariatric surgery at King Fahad Specialist Hospital in Buraydah, Saudi Arabia.

METHODS

 This was a non-randomized controlled trial conducted at King Fahd Specialist Hospital in Buraydah, Saudi Arabia. Visiting patients at first screening were enrolled based on eligibility criteria. Data were collected according to the given parameters such as gender, age, body mass index (BMI), duration of diabetes mellitus (DM), medications (insulin, oral antihyperglycemic agents, number of tablets if used, or no medications use), presence of comorbidities, such as hypertension and dyslipidemia, HbA1c level (before surgery and at third, sixth, and 12th months after surgery), and fasting blood glucose (FBG) level (before and after surgery).

RESULTS

A total of 96 diabetic patients were enrolled (35 males vs 61 females) with a mean age of 46.5 years. Laparoscopic sleeve gastrectomy was the most commonly performed surgery. The most common associated comorbidities were hypertension (50%) and hypothyroidism (14.6%). Results of the DiaRem scoring system showed 0-2 points in 15.6% patients, 3-7 points in 39.6% patients, 8-12 in 26% patients, 13-17 in 9.4% patients, and 18-22 in 9.4% patients. The lowest DiaRem score was associated with a higher value of BMI, shorter DM duration, and lower mean values of HbA1c and FBG post-surgery.

CONCLUSION

Consistent with the literature, our results indicated that those with an increased BMI, shorter duration of DM, and lower values of HbA1c post-FBG had a greater chance of diabetes remission postoperatively.

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.

Determinants of type 2 diabetes remission after bariatric surgery in obese Japanese patients: a retrospective cohort study

Objective

Bariatric surgery (BS) improves glycemic control in type 2 diabetes; however, some patients show insufficient improvement. Understanding the pathophysiology of type 2 diabetes in obese patients can facilitate appropriate treatment for type 2 diabetes after BS. The homeostatic model assessment (HOMA) 2 enables the calculation of the values from C-peptide data and evaluation of insulin users. We aimed to evaluate the pathophysiology of type 2 diabetes using pre- and postoperative parameters and HOMA2 in obese patients who underwent BS.

Methods

We retrospectively reviewed data from 45 obese patients with type 2 diabetes who underwent BS. They were followed-up for 12 months. The relationship between the HOMA2 score and complete remission (CR) of type 2 diabetes after BS was analyzed. Patients with and without CR were assigned to the CR and non-CR groups, respectively. Multiple regression analysis was used to identify factors associated with improvement in type 2 diabetes after BS.

Results

BS significantly improved body weight and glucose metabolism. The preoperative glycosylated hemoglobin A1c level and insulin secretion (HOMA2-%B) significantly differed between the CR and non-CR groups. Postoperative weight reduction and improved insulin sensitivity correlated significantly with CR; multiple regression showed that the preoperative HOMA 2-%B independently predicted CR of type 2 diabetes after BS.

Conclusion

Preoperative insulin secretion, improvement in insulin sensitivity, and weight reduction after BS are related to CR of type 2 diabetes after BS. The results better reveal the pathophysiology of and treatment for type 2 diabetes in obese patients who undergo BS.

Predictors of type 2 diabetes relapse after Roux-en-Y Gastric Bypass: a ten-year follow-up study

AIMS

To assess the impact of bariatric surgery on remission and relapse of type 2 diabetes mellitus (T2DM) at 10 years of follow-up and analyze predictive factors.

MATERIALS AND METHODS

Eighty-eight obese subjects undergoing Roux-en-Y gastric bypass (RYGB) and 25 subjects assigned to medical therapy (MT) were evaluated every year for 10 years. T2DM remission was defined by the American Diabetes Association criteria.

RESULTS

Body mass index (BMI), fasting glucose, and hemoglobin A1c (HbA1c) improved more markedly in RYGB than MT patients throughout the 10-year period. Post-surgery remission rates were 74% and 53% at 1 and 10 years, respectively, while remission did not occur in MT patients. One-year post-surgery, BMI decreased more in subjects with remission than in those without, but no further decrease was observed thereafter. By partial-least-squares analysis, T2DM duration, baseline HbA1c, and ensuing insulin therapy were the strongest predictors of remission. Remission was achieved at one year in 91% of patients with T2DM duration < 4 years, and 79% of them remained in remission at 10 years. On the contrary only 42% of patients with T2DM duration ≥ 4 years achieved remission, which was maintained only in 6% at the end of 10 years. By survival analysis, patients with T2DM duration < 4 years had higher remission rates than those with duration ≥ 4 years (hazards ratio (HR) 3.1 [95%CI 1.8-5.7]). Relapse did not occur before two years post-surgery and was much less frequent in patients with < 4- vs ≥ 4-year duration (HR 11.8 [4.9-29.4]).

CONCLUSIONS

Short T2DM duration and good glycemic control before RYGB surgery were the best requisites for a long-lasting T2DM remission, whereas weight loss had no impact on the long-term relapse of T2DM.

A 5-year assessment of the epidemiology and natural history of possible diabetes in remission

INTRODUCTION

Type 2 diabetes is considered a chronic and progressive disease. The term diabetes in remission has no consensus definition and the question whether diabetes "remission" or "cure" can achieve any long-term benefits in people with type 2 diabetes remains unclear. The aim of our study was a review of our district wide diabetes population to determine the epidemiology and clinical characteristics of those who had a diagnosis of diabetes but did not meet the diagnostic criteria for diabetes at the point of assessment in 2014 and then to review their diabetes outcomes over a 5-year time frame.

METHODS

In a whole population based non-interventional epidemiological study amongst 17,308 people with diabetes, we identified 991 with diet treated type 2 diabetes who met the baseline criteria for diabetes in remission (HbA1c < 48 mmol/mol (6.5%)). Over the next 5 years, 385 (39%) people had a cumulative HbA1c attainment of <48 mmol/mol (6.5%) and remained free of diabetes medication.

RESULTS

In this erstwhile remission group only 130 (13%) were free of any vasculopathy, whilst 255 (26%) had some form of micro or macrovascular disease, of which 64 people had been without micro or macrovascular vascular complications at baseline. Only 20 people had a HbA1c consistently ≤37 mmol/mol (5.7%) who were free of diabetes vascular complications and of diabetes medication.

CONCLUSIONS

The definition of 'diabetes in remission' remains unclear most especially regarding the inclusion of baseline prevalent or incident macro or microvascular disease, the durability of potential remission is poor, and the likelihood of cure is remote.

The effect of laparoscopic sleeve gastrectomy on type 2 diabetes remission outcomes in patients with body mass index higher than 25 kg/m2 but lower than 32.5 kg/m2

BACKGROUND

The effect of laparoscopic sleeve gastrectomy (LSG) in the treatment of type 2 diabetes (T2D) patients with body mass index (BMI is calculated by dividing weight in kilograms by height in meters squared) higher than 25 kg/m² but lower than 32.5 kg/m², especially in East Asian population characterized by abdominal obesity, are still unclear. This study aims to explore the effect of LSG in T2D patients with BMI higher than 25 kg/m² but lower than 32.5 kg/m².

METHODS

A total of 49 T2D patients with BMI(25-32.5 kg/m²) treated successfully with LSG were included in our study. The effect of LSG on T2D remission outcomes at 12 and 24 months after operation was analyzed.

RESULTS

All patients were treated successfully with LSG without conversion. The mean preoperative body weight,BMI, fasting plasma glucose, glycosylated hemoglobin (A1c) and fasting C-peptide were 81.7 ± 10.0 kg, 29.1 ± 2.4 kg/m², 10.4 ± 3.9 mmol/L,8.2 ± 1.5%, and 2.3 ± 1.1 nmol/L,respectively.The age, duration of diabetes and ABCD score were 48.6 ± 9.6 years,6.6 ± 5.1 years, and 2.9 ± 1.5. The mean fasting plasma glucose,A1c, and C-peptide levels were significantly decreased at 12 and 24 months after operation. At postoperative 24 months, 18 out of 49 patients (36.7%) reached diabetes complete remission (A1c levels≤6.0%).14 out of 49 patients (28.6%) reached partial remission (6.0% < A1c levels<6.5%). 8 out of 49 patients (16.3%) reached notable improvement (6.5% < A1c levels<7%). At 24 months after LSG, the complete remission rate of T2D patients with a BMI of 25-27.5 kg/m² was 35.3%, the complete remission rate of patients with a BMI of 27.5-30 kg/m² was 11.1%, and the complete remission rate of patients with a BMI of 30-32.5 kg/m² was 47.8%.At postoperative 24 months, the complete remission rate of T2D patients with ABCD score≤2 was 5.0%, the complete remission rate of patients with ABCD score 3 to 4 was 52.4%, and the complete remission rate of patients with ABCD score≥5 was 75.0%.

CONCLUSION

Our study demonstrates that LSG could result in a significant effect on T2D in patients with BMI 30-32.5 kg/m². In addition, our study indicates that higher ABCD score can predict a better diabetes remission outcome in diabetes patients with BMI ≤32.5 kg/m².

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.

Preoperative Bariatric Surgery Predictors of Type 2 Diabetes Remission

Obesity represents a significant proportion of the global public health burden, with the World Health Organization (WHO) estimating more than 600 million people are affected worldwide. Unfortunately, the epidemic of obesity is linked to the increased prevalence of associated metabolic diseases such as type 2 diabetes mellitus (T2DM). Bariatric surgery as an intervention has been shown to provide sustainable weight loss, and also leads to superior short- and long-term metabolic benefits including T2DM remission. Despite this added advantage conferred by bariatric surgery, emerging evidence has shown that not all patients with T2DM achieve remission postoperatively. As such, to improve patient selection and optimize preoperative counselling, research has focused on the preoperative predictors of T2DM remission following bariatric surgery. Herein, we provide a critical review of the current literature addressing preoperative predictors of T2DM remission and highlight the current gaps in the literature. The review comprised a multistage advanced electronic search of the Ovid/Medline, Embase, and Cochrane online libraries to identify available studies published over the last decade.

Evaluation of Clinical Factors Predictive of Diabetes Remission Following Bariatric Surgery

Bariatric surgery is an effective treatment for achieving significant weight loss and improving metabolic comorbidities such as type 2 diabetes mellitus (T2DM). The aim of our study was to investigate clinical factors related to T2DM remission in obese patients who had undergone bariatric surgery.

METHODS

A cohort of patients with T2DM and a minimum of class II obesity undergoing bariatric surgery had their clinical and anthropometric variables assessed. The statistical evaluation included multivariate analyses of clinical factors predicting a T2DM remission two years post-surgery.

RESULTS

83 patients were included (mean age 44.13 ± 10.38 years). Two years post-surgery, the percentage of excess weight lost was 63.43 ± 18.59%, and T2DM was resolved in 79.5% of the patients. T2DM remission was directly related to a high body mass index (BMI) (OR: 1.886; p = 0.022) and the absence of macro-vascular complications (OR: 34.667; p = 0.002), while it was inversely associated with T2DM with a duration longer than 5 years (OR: 0.022; p = 0.040) and baseline insulin treatment (OR: 0.001; p = 0.009). 15.6% of the patients presented early complications and 20.5% developed late complications.

CONCLUSION

In our study sample, bariatric surgery proved to be an effective and safe technique for sustained medium-term weight loss and the resolution of T2DM. A higher baseline BMI, a shorter T2DM duration, non-insulin treatment, and the absence of macro-vascular complications are factors predictive of T2DM remission.

Effect of Roux-en-Y Gastric Bypass for Patients with Type 2 Diabetes Mellitus and a BMI < 32.5 kg/m2: a 6-Year Study in Chinese Patients

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbidly obese patients to improve type 2 diabetes mellitus (T2DM). Recently, T2DM patients with a lower body mass index (BMI) have been receiving more attention, and these patients could benefit from RYGB.

METHODS

Fifty-two patients with T2DM underwent RYGB between October 2008 and December 2012 in our hospital. Weight, BMI, oral glucose tolerance test (OGTT), insulin release test (IRT), C-peptide release test (CRT), glycosylated hemoglobin (HbA1c), and lipid metabolic parameters were measured at baseline and at 3 and 6 months and 1, 2, 3, 4, 5, and 6 years after surgery.

RESULTS

The mean age of the 52 patients was 46.8 ± 9.5 years, and 57.7% were male. The mean duration of T2DM was 6.5 ± 4.6 years. Compared with the baseline values, weight and BMI were significantly decreased at several time points after surgery. HbA1c decreased from 8.2 ± 1.7% at baseline to 6.5 ± 1.4% at 3 months, 6.5 ± 1.4% at 6 months, 7.2 ± 1.3% at 4 years, and 7.5 ± 1.2% at 6 years. OGTT, OGTT-IRT, and OGTT-CRT improved after surgery. There was a decrease in triglycerides (TGs), total cholesterol (TC), and low-density lipoprotein (LDL) and an increase in high-density lipoprotein (HDL). At 6 years after surgery, 16.7% of patients achieved complete remission of T2DM, and 66.7% achieved improvement in T2DM.

CONCLUSION

RYGB may be a safe and effective treatment for T2DM patients with a BMI < 32.5 kg/m² in China. However, a long-term study without loss to follow-up is necessary for better evaluation.

Efficacy of Different Procedures of Metabolic Surgery for Type 2 Diabetes in Asia: a Multinational and Multicenter Exploratory Study

INTRODUCTION

Asian patients with diabetes exhibit different characteristics from Western patients. However, limited large-scale data are available on metabolic surgery procedures in Asia. We compared the short-term efficacies of metabolic surgery procedures for the management of Asian patients with different severities of diabetes.

METHODS

We included patients undergoing metabolic surgery in five Asian institutions from January 2008 to December 2015 with at least 1-year postoperative follow-up. Outcomes of weight loss and diabetes control were determined. Diabetes remission rates in different ABCD scores and factors affecting diabetes remission were analyzed.

RESULTS

A total of 1016 patients (mean BMI, 39.0 ± 7.2 kg/m²; HbA1c, 8.3% ± 1.7%) underwent metabolic surgery (197, Roux-en-Y gastric bypass [RYGB]; 171, one anastomosis gastric bypass [OAGB]; 437, sleeve gastrectomy [SG]; 130, SG with duodenal-jejunal bypass [SG-DJB]; and 81, single anastomosis duodenal-jejunal bypass with SG [SA-DJBSG]). The OAGB group exhibited significantly higher 1-year total weight loss (30.5%) and type 2 diabetes mellitus (T2DM) remission (78.4%) rates than did the other groups (p < .001). The patients with higher preoperative ABCD scores exhibited higher T2DM remission rates (81.8-100% and 9.5-46.2% in ABCD score subgroups of 9-10 and 1-2, respectively). In multivariate analysis, bypass was found to be an independent predictor of T2DM remission compared with SG (odds ratio of OAGB vs SG, 3.72; RYGB vs SG, 1.96; SG-DJB vs SG, 2.73; SA-DJBSG vs SG, 2.12).

CONCLUSION

The metabolic surgeries are highly effective in T2DM treatment. However, SG may not be as effective as gastric bypass and duodenal-jejunum bypass.

From Entero-Endocrine Cell Biology to Surgical Interventional Therapies for Type 2 Diabetes

The physiological roles of the enteroendocrine system in relation to energy and glucose homeostasis regulation have been extensively studied in the past few decades. Considerable advances were made that enabled to disclose the potential use of gastro-intestinal (GI) hormones to target obesity and type 2 diabetes (T2D). The recognition of the clinical relevance of these discoveries has led the pharmaceutical industry to design several hormone analogues to either to mitigate physiological defects or target pharmacologically T2D.Amongst several advances, a major breakthrough in the field was the unexpected observation that enteroendocrine system modulation to T2D target could be achieved by surgically induced anatomical rearrangement of the GI tract. These findings resulted from the widespread use of bariatric surgery procedures for obesity treatment, which despite initially devised to induce weight loss by limiting the systemic availably of nutrients, are now well recognized to influence GI hormone dynamics in a manner that is highly dependent on the type of anatomical rearrangement produced.This chapter will focus on enteroendocrine system related mechanisms leading to improved glycemic control in T2D after bariatric surgery interventions.

Impact of Bariatric Surgery in Reducing Macrovascular Complications in Severely Obese T2DM Patients

BACKGROUND

Evidence from real-world studies have suggested a reduced rate of macrovascular complications following bariatric surgery. We undertook this meta-analysis to investigate the impact of bariatric surgery on macrovascular disease outcomes in severely obese type 2 diabetes mellitus (T2DM) patients.

METHODS

An extensive literature search was performed in PubMed from inception until March 2020. All cohort studies assessing the association between bariatric surgery and macrovascular complications in severely obese T2DM patients were included. Two independent reviewers screened the articles, extracted data, and assessed the quality using the Newcastle-Ottawa Scale. The primary outcome was to assess the impact of bariatric surgery and the risk of macrovascular complications. Statistical analysis was performed using Review Manager 5.3.

RESULTS

This meta-analysis comprised of five studies including 49,211 participants (75% female), of which 14,434 underwent bariatric surgery and 34,777 underwent usual care. Participants who underwent bariatric surgery had a significantly lower risk of macrovascular complications as compared to those with non-surgical interventions (RR: 0.50 [95% CI: 0.35-0.73], p = 0.0003). In the subgroup analysis, based on the geographical regions, studies conducted in the USA showed a higher reduction (RR: 0.41 [95% CI: 0.32-0.53], p < 0.00001) in macrovascular complications as compared to other parts of the world. The risk of all-cause mortality was also significantly lower in patients with bariatric surgery (RR 0.39 [95% CI: 0.30-0.50], p < 0.00001).

CONCLUSION

Bariatric surgery was associated with a 50% reduction in macrovascular complications along with 61% reduction in risk of all-cause mortality in morbidly obese T2DM patients.

The influence of patient's age on metabolic and bariatric results of laparoscopic sleeve gastrectomy in 2-year observation

BACKGROUND

The incidence of obesity has been constantly growing and bariatric procedures are considered to be the most effective treatment solution for morbidly obese patients. The results of laparoscopic sleeve gastrectomy (LSG) may differ depending on patient's age, gender, preoperative body mass index (BMI) and physical activity.

METHODS

The aim of this study was to evaluate age-related differences in the outcome of LSG in terms of weight loss parameters, lipid and carbohydrate profile. The retrospective analysis of 555 patients who had undergone LSG was performed to compare the metabolic outcomes of surgery in individuals < 45 and ≥ 45 years old. Evaluation of weight loss parameters along with selected laboratory data was performed to demonstrate the results of LSG in 2 years follow-up.

RESULTS

Overall, 238 males and 317 females (43%/57%) with median age of 43 years and median preoperative BMI of 46.41 (42.06-51.02) kg/m2 were analyzed. Patients in both groups presented significant weight loss at 24 months after the surgery with comparable percentage of total weight loss (40.95% in < 45 years old group and 40.44% in ≥ 45 years old group). The percentage of excess weight loss (78.52% vs. 74.53%) and percentage of excess BMI loss (91.95% vs. 88.01%) were higher in patients < 45 years old. However, the differences were not statistically significant (p = 0.662, p = 0.788 respectively). Patients under 45 years old experienced faster decrease in fasting glucose level that was observed after only 3 months (109 mg/dl to 95 mg/dl in < 45 years old group vs. 103.5 mg/dl to 99.5 mg/dl in ≥ 45 years old group, p < 0.001). Both groups presented improvement of lipid parameters during the observation. However, patients < 45 years old achieved lower values of LDL at 3 and 12 months follow-up (115 mg/dl vs. 126 mg/dl, p = 0.010; 114.8 mg/dl vs. 122 mg/dl, p = 0.002). Younger group of patients also showed superior improvement of triglycerides level.

CONCLUSIONS

LSG results in significant weight loss in all patients regardless age. In turn, superior and faster improvement in lipid and carbohydrate profile is achieved in patients under 45 years old.

Metabolic Efficacy and Diabetes Remission Predictors Following 'Sleeve Gastrectomy with Loop Duodenojejunal Bypass' Surgery

PURPOSE

Laparoscopic sleeve gastrectomy with loop duodenojejunal bypass (SLDJB) is a novel metabolic surgery that is a modification of the single anastomosis duodenoileal bypass with sleeve. Compared to conventional surgeries, SLDJB is highly effective in inducing diabetes remission. This study analyzed the metabolic efficacy of SLDJB.

MATERIALS AND METHODS

Seventy-eight patients with obesity and diabetes who underwent SLDJB between May 2013 and October 2017 were retrospectively analyzed to investigate the efficacy of their surgery and diabetes remission predictors. Complete diabetes remission was defined as an HbA1_c level <6% with cessation of insulin and oral hypoglycemic agents.

RESULTS

Complete diabetes remission occurred in 80.52% and 76.71% of patients at 1- and 3-year follow-ups, respectively. There was no significant difference in the rates of complete diabetes remission between the groups based on gender, preoperative body mass index (BMI), diabetes duration or preoperative insulin use. There was a significantly higher rate of complete remission in patients <50 years of age at the 1-year follow-up. Additionally, the rate of complete remission was significantly less when preoperative glycemic control was poor. Preoperative HbA1_c levels negatively predicted complete remission, but was significant only at the 3-year follow-up.

CONCLUSION

SLDJB is highly effective in treating obesity with type 2 diabetes, and preoperative glycemic control was found to predict complete remission. Patients under 50 years of age had a better short-term response rate; however, the surgery was effective regardless of gender, preoperative BMI, duration of diabetes or preoperative insulin use.

The Use of Visceral Adiposity Index to Predict Diabetes Remission in Low BMI Chinese Patients After Bariatric Surgery

BACKGROUND

Visceral Adiposity Index (VAI) is considered to be a reliable indicator for evaluation of visceral adipose dysfunction and cardiovascular disease risk. However, no previous studies have reported the VAI variation after bariatric surgery and the predictive effect of preoperative VAI on diabetes remission. The aim of this study is to evaluate whether preoperative VAI is useful to predict diabetes remission in low BMI Chinese patients after bariatric surgery.

METHODS

Eighty-seven type 2 diabetes mellitus patients with BMI < 35 kg/m² underwent bariatric surgery from May 2010 to March 2018 in our hospital. VAI, glycolipid metabolic parameters, and anthropometric variables were measured before and 4 years after surgery. Complete remission was defined as follows: HbA1c < 6%, FPG < 5.6 mmol/L, achieved without anti-diabetic medication. Analysis included using binary logistic regression to identify predictors and ROC curves to determine clinically useful cutoff values.

RESULTS

Seventy-four patients (85.1%) underwent Roux-en-Y gastric bypass (RYGB), while the remaining 13 patients (14.9%) underwent sleeve gastrectomy (SG). Patients' weight, glycemic control, and lipid profiles were improved significantly after surgery (p < 0.05). Complete remission of T2DM was found in 35 patients (40.2%) 1 year after surgery. VAI decreased from baseline 4.41 to 1.74 in 3 months after surgery (p < 0.05) and showed a downward trend over the period from 6 months to 4 years. Patients with complete remission had a significantly shorter duration of diabetes, lower HbA1c level, and higher VAI, in comparison to those without remission. Binary logistics regression and ROC curves analysis confirm that VAI, HbA1c, and duration of diabetes can predict diabetes remission after bariatric surgery, and the VAI of 4.46 is a useful threshold for predicting surgical efficacy.

CONCLUSION

VAI is a significant predictor of diabetes remission for lower BMI patients with T2DM following bariatric surgery in China. The VAI of 4.46 is a useful threshold for predicting surgical efficacy. Multi-center and larger prospective studies are needed to confirm our findings.

Impact of preoperative HbA1c on postoperative complications after elective major abdominal surgery: a systematic review protocol

INTRODUCTION

Diabetes has an increasing worldwide prevalence. It is known to be a predisposing factor for postoperative complications. Preoperative glycaemic control strategies should be pursued as glycaemic control could serve as a modifiable risk factor. Glycated haemoglobin (HbA1c), a marker of 3-month average glycaemic control, has been shown in meta-analyses to predict postoperative complications in cardiothoracic, bariatric and orthopaedic surgery. However, there is no meta-analysis in the major abdominal surgery population, in whom morbidity may be higher due to the nature of the surgery. Understanding the association between HbA1c and postoperative complications could help in preoperative risk prognostication, counselling and glycaemic target selection. The aim of this systematic review and meta-analysis is to evaluate all evidence on the association between preoperative HbA1c and postoperative complications in elective major abdominal surgery, and to investigate the threshold HbA1c level before postoperative complication rates increase.

METHODS AND ANALYSIS

This review will be performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. PubMed, Embase, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure will be searched for all original studies. Study selection, data extraction, risk of bias and quality assessment will be conducted by two independent reviewers. The primary outcome is the association between preoperative HbA1c and major postoperative complications (Clavien Dindo 3-5), and the secondary outcome is the association between HbA1c and overall postoperative complications. Data management and synthesis will be performed using Microsoft Excel and Stata to derive pool estimates.

ETHICS AND DISSEMINATION

No ethics approval is required as only secondary data will be used. Findings will be disseminated through peer-reviewed journals and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020167347.

Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group, randomised controlled trial

BACKGROUND

Type 2 diabetes is affecting people at an increasingly younger age, particularly in the Middle East and in north Africa. We aimed to assess whether an intensive lifestyle intervention would lead to significant weight loss and improved glycaemia in young individuals with early diabetes.

METHODS

This open-label, parallel-group, randomised controlled trial (DIADEM-I), done in primary care and community settings in Qatar, compared the effects of an intensive lifestyle intervention with usual medical care on weight loss and glycaemic outcomes in individuals with type 2 diabetes, aged 18-50 years, with a short diabetes duration (≤3 years), had a BMI of 27·0 kg/m² or more, and who were from the Middle East and north Africa region. Participants were randomly allocated (1:1) either to the intensive lifestyle intervention group or the usual medical care control group by a computer-generated sequence and an online randomisation service. The intensive lifestyle intervention comprised a total diet replacement phase, in which participants were given formula low-energy diet meal replacement products followed by gradual food reintroduction combined with physical activity support, and a weight-loss maintenance phase, involving structured lifestyle support. Participants in the control group received usual diabetes care, which was based on clinical guidelines. The primary outcome was weight loss at 12 months after receiving the assigned intervention. Our analysis was based on the intention-to-treat principle. Key secondary outcomes included diabetes control and remission. The trial was registered with the ISRCTN registry, ISRCTN20754766, and ClinicalTrials.gov, NCT03225339.

FINDINGS

Between July 16, 2017, and Sept 30, 2018, we enrolled and randomly assigned 158 participants (n=79 in each group) to the study. 147 participants (70 in the intervention group and 77 in the control group) were included in the final intention-to-treat analysis population. Between baseline and 12 months, the mean bodyweight of participants in the intervention group reduced by 11·98 kg (95% CI 9·72 to 14·23) compared with 3·98 kg (2·78 to 5·18) in the control group (adjusted mean difference -6·08 kg [95% CI -8·37 to -3·79], p<0·0001). In the intervention group, 21% of participants achieved more than 15% weight loss between baseline and 12 months compared with 1% of participants in the control group (p<0·0001). Diabetes remission occurred in 61% of participants in the intervention group compared with 12% of those in the control group (odds ratio [OR] 12·03 [95% CI 5·17 to 28·03], p<0·0001). 33% of participants in the intervention group had normoglycaemia compared with 4% of participants in the control group (OR 12·07 [3·43 to 42·45], p<0·0001). Five serious adverse events were reported in four participants in the control group; four admissions to hospital because of unanticipated events (supraventricular tachycardia, abdominal pain, pneumonia, and epididymo-orchitis), and one admission to hospital for an anticipanted event (hyperglycaemia).

INTERPRETATION

Our findings show that the intensive lifestyle intervention led to significant weight loss at 12 months, and was associated with diabetes remission in over 60% of participants and normoglycaemia in over 30% of participants. The provision of this lifestyle intervention could allow a large proportion of young individuals with early diabetes to achieve improvements in key cardiometabolic outcomes, with potential long-term benefits for health and wellbeing.

FUNDING

Qatar National Research Fund.

Factors associated with complete and partial remission, improvement, or unchanged diabetes status of obese adults 1 year after sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) achieves type 2 diabetes (T2D) remission to various extents, and reasons for such variations are unknown.

OBJECTIVES

We assessed patients' characteristics associated with T2D remission 1 year post SG.

SETTING

University hospital.

METHODS

Retrospective study of 230 T2D patients (18-64 yr) who underwent SG at our institution. We examined pre- and postoperative demographic, anthropometric, biochemical, and clinical characteristics associated with T2D complete remission, partial remission, improvement, or unchanged status. Independent predictors of T2D complete remission were assessed by binary logistic regression and then included in 7 predictive models. Logistic regression assessed the pre- and postoperative predictors of T2D complete remission and their predictive performance was measured with the area under the curve of the receiver operating characteristic curve.

RESULTS

A total of 230 patients were included in the study, females comprised 69%, and mean age was 45.66 ± 8.84 years. Mean preoperative weight and body mass index were 115.69 ± 20.76 kg and 43.53 ± 6.98 kg/m², respectively. Approximately two thirds (64.4%) of the sample had diabetes for >5 years. Insulin therapy users comprised 36.9% of the sample and 29.6% of patients were on ≥2 oral hypoglycemic agents (OHA). At 1 year, mean body mass index was 32.77 ± 6.09 kg/m², percent excess weight loss (%EWL) was 62.29 ± 23.60% and glycosylated hemoglobin (HbA1C) improved from 8.1% to 6.18%. Approximately 42.2% of the sample achieved T2D complete remission. Compared with those with no remission, patients with complete remission were significantly younger, had shorter duration of diabetes, were not on insulin therapy, took fewer OHA, had higher C-peptide, lower preoperative HbA1C, were less likely to have had hypertension or dyslipidemia, and more likely to have achieved higher %EWL. Seven proposed models for prediction of complete remission showed the most useful model comprised diabetes duration + pre-HbA1C + %EWL + insulin therapy + age + OHA (area under the curve = .81). Independent predictors of complete remission were preoperative HbA1C, %EWL, insulin therapy, age, and OHA (but not diabetes duration).

CONCLUSION

SG results in significant weight reduction and various extents of T2D remission. HbA1C, %EWL, insulin therapy, age, and OHA were independent predictors of complete remission. Assessing these factors before bariatric surgery is important to identify any modifiable characteristics that can be altered to increase the likelihood of remission.

Preoperative predictors of early relapse/no-remission of type-2 diabetes after metabolic surgery in Chinese patients

Remission of type 2 diabetes mellitus (T2DM) after metabolic surgery in some patients is not sustained. There is limited data regarding the preoperative factors predicting early relapse of T2DM in Chinese patients. The objective of this study is to look for preoperative predictors of early T2DM relapse/no remission in patients with obesity and diabetes who underwent Roux-en-Y gastric bypass (RYGB) or loop duodeno-jejunal bypass with sleeve gastrectomy (LDJB-SG). This is a retrospective study of 113 patients who underwent RYGB or LDJB-SG for T2DM. All T2DM patients with BMI 27.5 to 37.5 kg/m² , having uncontrolled diabetes and T2DM patients with BMI > 37.5 were included in the study. A multivariate analysis with a logistic regression model was used for analysed factors. Nineteen patients (16.8%) had early relapse and 12 (10.6%) did not have remission. Mean age of patients was significantly more who relapsed/no-remission (44.9 vs 40.3 years). On univariate analysis, base line weight (86 vs 96.7 kg) was significantly lower in patients who relapsed/no-remission. Patients with sustained remission had statistically significant low glycosylated haemoglobin (P < .030), plasma glucose (120 minutes) (P < .002) on OGTT, area under curve glucose (P < .011) values and more C-peptide (P < .006) on univariate analysis. Only duration of diabetes (OR 2.78, 95% CI 1.56-4.97, P < .001) was found to be independent preoperative factor associated with early relapse/no-remission. Two years of diabetes duration was the cut-off point to predict relapse/no-remission (sensitivity 78.9, specificity 63.4, receiver operating characteristic curve 0.71). Duration of diabetes is the most probable, independent preoperative predictor of early T2DM relapse/no-remission in patient with obesity and diabetes undergoing metabolic surgery.

Validating Risk Prediction Models of Diabetes Remission After Sleeve Gastrectomy

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

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.

Preoperative Circulating Succinate Levels as a Biomarker for Diabetes Remission After Bariatric Surgery

OBJECTIVE

To determine the potential use of baseline circulating succinate to predict type 2 diabetes remission after bariatric surgery.

RESEARCH DESIGN AND METHODS

Forty-five obese patients with diabetes were randomly assigned to Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or laparoscopic greater curvature plication. Anthropometric parameters were evaluated, and a complete biochemical analysis including circulating serum succinate concentrations was performed at baseline and 1 year after surgery. The results were externally validated in a second cohort including 88 obese patients with diabetes assigned to RYGB or SG based on clinical criteria.

RESULTS

Succinate baseline concentrations were an independent predictor of diabetes remission after bariatric surgery. Patients achieving remission after 1 year had lower levels of baseline succinate (47.8 [37.6-64.6] µmol/L vs. 64.1 [52.5-82.9] µmol/L; P = 0.018). Moreover, succinate concentrations were significantly decreased 1 year after surgery (58.9 [46.4-82.4] µmol/L vs. 46.0 [35.8-65.3] µmol/L, P = 0.005). In multivariate analysis, the best logistic regression model showed that baseline succinate (odds ratio [OR] 11.3, P = 0.031) and the type of surgery (OR 26.4, P = 0.010) were independently associated with remission. The C-statistic for this model was 0.899 (95% CI 0.809-0.989) in the derivation cohort, which significantly improved the prediction of remission compared with current available scores, and 0.729 (95% CI 0.612-0.846) in the validation cohort. Interestingly, patients had a different response to the type of surgery according to baseline succinate, with significant differences in remission rates.

CONCLUSIONS

Circulating succinate is reduced after bariatric surgery. Baseline succinate levels have predictive value for diabetes remission independently of previously described presurgical factors and improve upon the current available scores to predict remission.