The long-term effects of bariatric surgery for type 2 diabetes: systematic review and meta-analysis of randomized and non-randomized evidence. Obes Surg. 2015;25:143-158. [PMID: 25355456 DOI: 10.1007/s11695-014-1460-2]

Pharmacological treatment of non-responders following bariatric surgery

Obesity is a complex chronic disease and requires a long-term multidisciplinary management. Even patients undergoing bariatric surgery, one the most effective treatments for obesity, can have insufficient weight loss (IWL) than expected (primary non responder) or weight regain (WR) after a successful primary procedure (secondary non responder). A poor response represents a challenge of bariatric surgery that can induce persistence or recurrence of obesity-related comorbidities, prejudicing benefits of surgery. Increasing evidence suggests that weight loss medications represent a useful strategy in obesity care also after bariatric surgery procedures. This narrative review summarizes the evidence concerning anti-obesity therapy in the management of no-responders to primary bariatric surgery. Available data on liraglutide (one randomized double-blind placebo-controlled trial, three prospective and three retrospective studies), naltrexone/bupropion (three retrospective studies), orlistat (one case control prospective and one retrospective studies) and topiramate and phentermine (five retrospective studies) have been considered. Available data suggest that weight loss medications could offer a significant adjunctive benefit to lifestyle and behavioral modifications in the life-long management of obesity. Newer treatment modalities including the use of anti-obesity drugs provide patients and healthcare providers with more options in the management of poor response after bariatric surgery.

Continued Diabetes Remission Despite Weight Recurrence: Gastric Bypass Long-Term Metabolic Benefit

BACKGROUND

Roux-en-Y gastric bypass (RYGB) demonstrates high rates of type 2 diabetes mellitus (T2DM) remission, a phenomenon hypothesized to be mediated mainly by weight loss. Compared with procedures that do not bypass the proximal small intestines, such as sleeve gastrectomy (SG), RYGB exhibits weight loss-independent intestinal mechanisms conducive to T2DM remission. We investigated continued diabetes remission (CDR) rates despite weight recurrence (WR) after RYGB compared with an SG cohort.

STUDY DESIGN

A retrospective review of patients who underwent successful primary RYGB or SG with a BMI value of 35 kg/m 2 or more and a preoperative diagnosis of T2DM was performed. Patients with less than 5 years of follow-up, absence of WR, or lack of T2DM remission at nadir weight were excluded. After selecting the optimal procedure for glycemic control, rates of CDR were then stratified into WR quartiles and compared.

RESULTS

A total of 224 RYGB and 46 SG patients were analyzed. The overall rate of CDR was significantly higher in the RYGB group (75%) compared with the SG group (34.8%; p < 0.001). The odds of T2DM recurrence were 5.5 times higher after SG compared with RYGB. Rates of CDR were stratified into WR quartiles (85.5%, <25%; 81.7%, 25% to 44.9%; 63.2%, 45% to 74.9%; and 60%, >75%). Baseline insulin use, higher preoperative glycosylated hemoglobin, and longer preoperative duration of T2DM were associated with T2DM recurrence, whereas WR was not.

CONCLUSIONS

T2DM remission rates after RYGB are maintained despite WR, arguing for a concurrent weight loss-independent metabolic benefit likely facilitated by bypassing the proximal small intestine.

Impact of Bariatric Surgery on Treatment Burden and Progression of Diabetic Retinopathy

Purpose: To assess the severity, progression, and treatment burden of diabetic retinopathy (DR) in patients after bariatric surgery compared with controls. Methods: A retrospective cohort study was performed of patients with type 2 diabetes and DR seen at the Duke Eye Center between 2014 and 2023. Clinical data included hemoglobin A1c (HbA1c), diagnostic stage of DR, diabetic macular edema (DME) or vitreous hemorrhage (VH), visual acuity (VA), and treatment burden at baseline and follow-up. Generalized estimating equation analysis was used to account for the correlation between 2 eyes of the same patient. Results: Sixteen patients who had bariatric surgery were matched by age, sex, and duration of diabetes with 60 control patients managed medically during the same time period. The HbA1c level, severity of DR, presence of DME or VH, VA, and treatment burden were not significantly different (all P > .05) at the baseline examination. On average, patients were followed for 6 years. The HbA1c level at the follow-up was significantly lower in the bariatric surgery group (6.4% vs 8.5%; P < .001). At the follow-up, the treatment burden was reduced in the bariatric surgery group compared with the control group (P = .04). There was a clear trend toward reduced progression of DR and treatment burden in the bariatric surgery group over the follow-up. Conclusions: Bariatric surgery may improve glycemic control, stabilize DR progression, and reduce the treatment burden, which may have a significant impact on quality of life for patients with DR.

Obesity management: sex-specific considerations

Obesity is a global health issue that has grown to epidemic proportions. According to World Health Organisation (WHO), overweight and obesity are responsible for more than 1.2 million deaths in Europe each year, representing > 13% of the region's total mortality. Highly processed, calorie-dense foods and reduced physical activity are considered as primary drivers of obesity, but genetic predisposition also plays a significant role. Notably, obesity is more prevalent in women than in men in most countries, and several obesity-related comorbidities exhibit sex-specific pathways. Treatment indication depends on BMI (body mass index), as well as existing comorbidities and risk factors. To reduce obesity-associated comorbidities, a permanent reduction in body weight of (at least) 5-10% is recommended. Treatment guidelines suggest an escalating stepwise approach including lifestyle intervention, pharmacotherapy, and bariatric-metabolic surgery. As cumulative evidence suggests differences in weight loss outcomes, there is growing interest in sex-specific considerations in obesity management. However, most trials do not report weight loss or changes in body composition separately for women and men. Here, we discuss state-of-the-art obesity management and focus on current data about the impact of sex on weight loss outcomes.

Potential Therapeutic Targets in Obesity, Sleep Apnea, Diabetes, and Fatty Liver Disease

Obesity and metabolic syndrome affect the majority of the US population. Patients with obesity are at increased risk of developing type 2 diabetes (T2DM), obstructive sleep apnea (OSA), and metabolic dysfunction-associated steatotic liver disease (MASLD), each of which carry the risk of further complications if left untreated and lead to adverse outcomes. The rising prevalence of obesity and its comorbidities has led to increased mortality, decreased quality of life, and rising healthcare expenditures. This phenomenon has resulted in the intensive investigation of exciting therapies for obesity over the past decade, including more treatments that are still in the pipeline. In our present report, we aim to solidify the relationships among obesity, T2DM, OSA, and MASLD through a comprehensive review of current research. We also provide an overview of the surgical and pharmacologic treatment classes that target these relationships, namely bariatric surgery, the glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and glucagon receptor agonists.

Efficacy of High-dose Liraglutide 3.0 mg in Patients with Poor Response to Bariatric Surgery: Real-world Experience and Updated Meta-analysis

PURPOSE

Poor response to bariatric surgery, characterized by insufficient weight loss (IWL) or weight regain (WR), poses a significant challenge in obesity treatment. This study aims to assess the effectiveness of liraglutide in addressing this issue.

MATERIALS AND METHODS

A retrospective, multicenter cohort study investigated the impact of liraglutide 3 mg on weight loss in adults with suboptimal responses or weight regain after bariatric surgery (BS). Additionally, a systematic review and meta-analysis were conducted for a comprehensive evaluation.

RESULTS

A total of 119 patients (mean age 41.03 ± 11.2 years, 71.4% female) who experienced IWL or WR after BS received pharmacologic therapy with liraglutide 3 mg. Mean percent weight loss in the entire cohort was 5.6 ± 2.6% at 12 weeks and 9.3 ± 3.6% at 24 weeks with a significant reduction in waist circumference (p < 0.0001). No serious side effects were reported. A meta-analysis, utilizing the fixed effect model with the metafor package in R, included 6 and 5 papers for the change in body weight and BMI after liraglutide treatment, respectively. The analysis demonstrated a considerable reduction in body weight (7.9; CI - 10.4; - 5.4, p < 0.0001) and BMI (3.09; CI 3.89; - 2.28, p < 0.0001).

CONCLUSION

Liraglutide 3 mg emerges as a viable option for significant weight loss in patients experiencing IWL or WR after BS. Its inclusion in a multimodal, sequential obesity treatment approach proves promising.

Prediabetes remission after bariatric surgery: a 4-years follow-up study

BACKGROUND

Bariatric surgery leads to weight loss and to cardiometabolic risk improvement. Although prediabetes remission after bariatric surgery is biologically plausible, data on this topic is scarce. We aimed to assess prediabetes remission rate and clinical predictors of remission in a 4 year follow up period.

METHODS

Observational longitudinal study including patients with obesity and prediabetes who had undergone bariatric surgery in our centre. Prediabetes was defined as having a baseline glycated haemoglobin (A1c) between 5.7% and 6.4% and absence of anti-diabetic drug treatment. We used logistic regression models to evaluate the association between the predictors and prediabetes remission rate.

RESULTS

A total of 669 patients were included, 84% being female. The population had a mean age of 45.4 ± 10.1 years-old, body mass index of 43.8 ± 5.7 kg/m2, and median A1c of 5.9 [5.8, 6.1]%. After bariatric surgery, prediabetes remission rate was 82%, 73%, 66%, and 58%, respectively in the 1st, 2nd, 3rd, and 4th years of follow-up. Gastric sleeve (GS) surgery was associated with higher prediabetes remission rate than Roux-en-Y gastric bypass surgery in the 3rd year of follow-up. Men had a higher remission rate than women, in the 1st and 3nd years of follow-up in the unadjusted analysis. Younger patients presented a higher remission rate comparing to older patients in the 3rd year of follow-up.

CONCLUSION

We showed a high prediabetes remission rate after bariatric surgery. The remission rate decreases over the follow-up period, although most of the patients maintain the normoglycemia. Prediabetes remission seems to be more significant in patients who had undergone GS, in male and in younger patients.

Cost-Effectiveness of Bariatric Surgery in Patients Living with Obesity and Type 2 Diabetes

Aims

The favourable effects of bariatric surgeries on body weight reduction and glucose control have been demonstrated in several studies. Additionally, the cost-effectiveness of bariatric surgeries has been confirmed in several analyses. The aim of the current analysis was to demonstrate the cost-effectiveness of bariatric surgeries in obese patients with type 2 diabetes in Hungary compared to conventional diabetes treatments based on economic modelling of published clinical trial results.

Materials and Methods

Patients entered the simulation model at the age of 45 with body mass index (BMI) ≥ 30 kg/m2 and type 2 diabetes. The model was performed from the public payer's perspective, comparing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) procedures to conventional care of diabetes. The results were provided separately for three BMI categories.

Results

The base-case analysis demonstrated that both surgery types were dominant; i.e., they saved 17 064 to 24 384 Euro public payer expenditures and resulted in improved health outcomes (1.36 to 1.50 quality-adjusted life years gain (QALY)) in the three BMI categories. Bariatric surgeries extended the life expectancy and the disease-free survival times of all the investigated diabetes complications. All the scenario analyses confirmed the robustness of the base-case analysis, such that bariatric surgeries remained dominant compared to conventional diabetes treatments.

Conclusion

The results of this cost-effectiveness analysis highlight the importance of bariatric surgeries as alternatives to conventional diabetes treatments in the obese population. Therefore, it is strongly recommended that a wider population has access to these surgeries in Hungary.

Effects of obesity, and of weight loss following bariatric surgery, on methylation of DNA from the rectal mucosa and in cell-free DNA from blood

BACKGROUND

DNA methylation is an epigenetic mechanism through which environmental factors including nutrition and inflammation influence health. Obesity is a major modifiable risk factor for many common diseases including cardiovascular diseases and cancer. In particular, obesity-induced inflammation resulting from aberrantly-methylated inflammatory genes may drive risk of several non-communicable diseases including colorectal cancer (CRC). This study is the first to investigate the effects of weight loss induced by bariatric surgery (BS) on DNA methylation in the rectum and in cell-free DNA (cfDNA) from blood.

SUBJECTS AND METHODS

DNA methylation was quantified in rectal mucosal biopsies and cfDNA from serum of 28 participants with obesity before and 6 months after BS, as well as in 12 participants without obesity (control group) matched for age and sex from the Biomarkers Of Colorectal cancer After Bariatric Surgery (BOCABS) Study. DNA methylation of LEP, IL6, POMC, LINE1, MAPK7 and COX2 was quantified by pyrosequencing.

RESULTS

BMI decreased significantly from 41.8 kg/m2 pre-surgery to 32.3 kg/m2 at 6 months after BS. Compared with the control group, obesity was associated with lower LEP methylation in both the rectal mucosa and in cfDNA from serum. BS normalised LEP methylation in DNA from the rectal mucosa but not in cfDNA. BS decreased methylation of some CpG sites of LINE1 in the rectal mucosal DNA and in cfDNA to levels comparable with those in participants without obesity. Methylation of POMC in rectal mucosal DNA was normalised at 6 months after BS.

CONCLUSION

BS reversed LINE1, POMC and LEP methylation in the rectal mucosa of patients with obesity to levels similar to those in individuals without obesity. These findings support current evidence of effects of BS-induced weight loss on reversibility of DNA methylation in other tissues. The DNA methylation changes in the rectal mucosa shows promise as a biomarker for objective assessment of effects of weight loss interventions on risk of cancer and other diseases.

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.

High-dose liraglutide improves metabolic syndrome in poor responders to bariatric surgery

Background

Bariatric surgery (BS) represents the most effective therapy for obesity class III, or class II with at least one weight-related comorbidity. However, some patients have insufficient weight loss or clinically relevant weight regain after a successful primary procedure. This study aimed to assess the efficacy of liraglutide treatment on weight loss, body composition and improvement of metabolic syndrome (MS) in patients defined as poor responders after BS.

Methods

The study involved 59 non-diabetic adults with obesity (M/F: 17/42, age: 38.6 ± 11.8 years, BMI 38.3 ± 5.5 kg/m2) who had been treated with BS and experienced a poor response, categorized as either IWL (insufficient weight loss) or WR (weight regain). All patients were prescribed pharmacological therapy with liraglutide and attended nutritional counseling. Anthropometric and clinical measurements, body composition and the presence of MS defined according to the ATP-III classification were evaluated before starting liraglutide and after 24 weeks of treatment.

Results

After 24 weeks of treatment with liraglutide, the mean weight loss was 8.4% ± 3.6% with no difference between gender, bariatric procedure, or type of poor response (IWL or WR). A significant decrease in fat mass, free-fat mass and total body water was documented. After 24 weeks, patients presented significantly lowered fasting glucose, total cholesterol, triglycerides, AST and ALT. The prevalence of MS was reduced from 35% at baseline to 1.6% after 24 weeks. No patients discontinued the treatment during the study.

Conclusion

In patients who experience poor response after BS, liraglutide is well tolerated and promotes significant weight loss, ameliorates cardiometabolic comorbidities, and reduces the prevalence of MS.

Mid-Long-Term Effect of Metabolic Surgery on Type 2 Diabetes in Nonobese Patients: a Meta-analysis

BACKGROUND

This study aimed to perform a meta-analysis regarding the mid-long-term effect (≥ 2-year follow-up) of metabolic surgery on T2DM in non-obese patients.

METHODS

PubMed, EMBASE and CENTRAL databases were searched for clinical studies from inception to March 2023. Stata 12.0 was used for data aggregation. Sensitivity, subgroup, and meta-regression analyses were performed when feasible.

RESULTS

This meta-analysis included 18 articles involving 548 patients. A pooled rate of 47.5% of T2DM remission was found after metabolic surgery. To be more specific, 83.5% was obtained for hemoglobin A1c (HbA1c) < 7.0%, 45.1% for HbA1c < 6.5%, and 40.4% for HbA1c < 6.0%. Subgroup analysis showed that one-anastomosis gastric bypass (OAGB) had a higher remission rate (93.9%) than other surgeries. Studies conducted in America had a higher remission rate (61.4%) than in Asia (43.6%). Meta-regression analysis displayed that publication year, number of patients, study design, preoperative age, BMI, and quality assessment score were not significantly associated with T2DM remission rate. Additionally, metabolic surgery could result in significant reductions in BMI (-4.133 kg/m2), weight (-9.874 kg), HbA1c (-1.939%), fasting blood glucose, fasting C-peptide, and fasting insulin. However, metabolic surgery seemed to have poorer glycemic control in non-obese than obese T2DM patients.

CONCLUSION

A moderate mid-long-term effect of T2DM remission was observed after metabolic surgery in non-obese patients. However, we still need more prospective multi-institutional studies using the same definitions for diabetes and the same surgical technique for the surgery. Without this, the exact role of bariatric surgery in non-obese patients is unanswered.

Racial disparities in reasons for mortality following bariatric surgery

BACKGROUND

Metabolic and bariatric surgery (MBS) remains a safe and effective treatment for patients with severe obesity. Recent studies have highlighted racial disparities in perioperative outcomes, including up to a twofold higher mortality rate in non-Hispanic black (NHB) (vs. non-Hispanic white (NHW)) patients. Causality for these disparate outcomes remains unclear and largely unexplored.

OBJECTIVE

Our study aim was to determine reasons for mortality among racial and ethnic cohorts and MBS patients.

SETTING

Academic Hospital.

METHODS

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases were identified using the 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) database using current procedural (CPT) codes 43,664, 43,645, and 43,775. Multivariate regression analyses were performed to determine independent predictors of overall and bariatric-related mortality. Reasons for mortality were identified and compared between racial and ethnic cohorts.

RESULTS

Of 650,903 RYGB and SG cases, 512,041 were included in our analysis (73% SG). For the entire cohort, all-cause and bariatric-related mortality rates were 0.095% and 0.05%, respectively. Age, male gender, ASA 4, functional status, therapeutic anticoagulation, smoking, COPD, and RYGB were independently associated with both overall and bariatric-related mortality. NHB had increased odds (2.13, p < 0.001) of bariatric-related mortality. Compared to NHW patients (13.3%), venous thromboembolic (VTE) complication was the most common reason for overall mortality in NHB (27.8%) and Hispanic (25%) patients (p < 0.001). VTE-related mortality directly associated with the bariatric procedure was also higher in NHB (34.6%) and Hispanic (33.3%) (vs. NHW 21.0%) patients (p 0.05). When stratified by procedure, mortality causes in RYGB cases were similar between racial and ethnic cohorts. In the SG cohort, the proportion of VTE-related mortality varied significantly (p 0.043) between NHB (39.2%), Hispanic 40.0%, and NHW (20.5%) patients.

CONCLUSION

There are racial and ethnic differences in causes of mortality following bariatric surgery. The predominant cause of overall and bariatric-related mortality in NHB bariatric surgery patients is postoperative venous thromboembolism. More granular MBSAQIP data capture is needed to determine the role of patient risk versus practice patterns in these disparate outcomes.

Factors influencing bariatric surgery outcomes

The outcomes of bariatric surgery, while often impressive, are not universally satisfactory; they vary from patient to patient and from operation to operation. Between 20-30% of patients experience suboptimal weight loss or substantial weight regain early in their postoperative course. Confronted with this chronic disease, and given that failures are difficult to manage, it is essential to better characterize obesity preoperatively, considering other metrics beyond just the body mass index (BMI), to select the best candidates for surgery and optimize the benefit/risk ratio. Based on the data of the most recent studies on bariatric surgery, our objective is to identify the predictive factors of weight loss as well as the risk factors of failure. Our analysis indicates that the choice of the surgical technique, age, initial BMI, ethnic origin, the presence of eating disorders and metabolic factors all have an impact on weight-loss outcomes after bariatric surgery. Thus, it is of major importance to carefully select patients during a preoperative multidisciplinary discussion in order to optimize weight loss and metabolic outcomes.

Metabolic surgery versus usual care effects on diabetes remission: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery is superior to usual care for diabetes remission. Previous meta-analyses were limited by pooling observational and randomized trials, using various definitions of diabetes remission, and not controlling for various diabetes medications. The current meta-analysis aimed to compare bariatric surgery and usual care regarding the same.

METHODS

We searched PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Library for relevant articles from the date of the first inception up to February 2023. The keywords diabetes remission, Bariatric surgery, metabolic surgery, lifestyles, usual care, GLIP-1 agonists, insulin use, gastric banding, biliopancreatic diversion, sleeve gastrectomy, and Roux-en-Y gastric bypass, were used. A datasheet was used to extract the relevant data.

RESULTS

Diabetes remission (complete and prolonged) was higher among bariatric surgeries compared to usual care, odd ratio, 0.06, 95 CI, 0.02-0.25 and 0.12, 95 CI, 0.02-0.72, respectively. bariatric surgery patients were younger, had higher HbA1c, odd ratio, - 3.13, 95 CI, - 3.71 to 2.54, and 0.25, 95 CI, 0.02-0.48, respectively, insulin use was higher, and glucagon-like peptide agonists use was lower among bariatric surgery patients, odd ratio, 0.49, 95% CI, 0.24-0.97, and 3.06, 95% CI, 1.44-6.53, respectively.

CONCLUSION

Bariatric surgery was better than usual care in diabetes remission. Bariatric surgery patients were younger, had higher HbA1c, and received more insulin and lower GLP-1 agonists. No differences were evident regarding body mass index and the duration of diabetes. Further trials comparing the new anti-diabetic medications and different forms of bariatric surgery and controlling for the level of exercise and diet are recommended.

The role of the gastric fundus in glycemic control

PURPOSE

Ghrelin, one of the most studied gut hormones, is mainly produced by the gastric fundus. Abundant evidence exists from preclinical and clinical studies underlining its contribution to glucose regulation. In the following narrative review, the role of the gastric fundus in glucose regulation is summarized and we investigate whether its resection enhances glycemic control.

METHODS

An electronic search was conducted in the PubMed® database and in Google Scholar® using a combination of medical subject headings (MeSH). We examined types of metabolic surgery, including, in particular, gastric fundus resection, either as part of laparoscopic sleeve gastrectomy (LSG) or modified laparoscopic gastric bypass with fundus resection (LRYGBP + FR), and the contribution of ghrelin reduction to glucose regulation.

RESULTS

Fourteen human studies were judged to be eligible and included in this narrative review. Reduction of ghrelin levels after fundus resection might be related to early glycemic improvement before significant weight loss is achieved. Long-term data regarding the role of ghrelin reduction in glucose homeostasis are sparse.

CONCLUSION

The exact role of ghrelin in achieving glycemic control is still ambiguous. Data from human studies reveal a potential contribution of ghrelin reduction to early glycemic improvement, although further well-designed studies are needed.

Weight-centric treatment of type 2 diabetes mellitus

Background

Chronic non-communicable diseases (CNCD) represent a major cause of morbidity and mortality. Type 2 diabetes mellitus (T2DM) is one of the most prevalent CNCD that is associated with a significant medical and economic burden. One of the main modifiable risk factors of T2DM is obesity. Many medications used for T2DM can lead to weight gain, worsening one of the root causes of this disease.

Methods

In this clinical review, we study the effect of medications for T2DM on body weight. We used MEDLINE, Google scholar, PubMed, Scopus, and Embase databases to search for relevant studies between 1 January 1950 to 20 September 2022 in English language. Here, we review the most prescribed medications for T2DM and summarize their effect on patients' body weight. We will also present an expert opinion on a recommended weight-centric approach to treat T2DM.

Results

Multiple T2DM medications have been associated with weight gain. Insulin, sulfonylureas, thiazolidinediones and meglitinides may increase body weight. However, biguanides (e.g., metformin), glucagon-like peptide-1 agonists (e.g., semaglutide, liraglutide, tirzepatide), sodium-glucose cotransporter 2 inhibitors, and amylin analogs (e.g., pramlintide) are associated with significant weight loss. Dipeptidyl peptidase-4 inhibitors are considered weight neutral medications. Experts in the fields of endocrinology and obesity recommend utilizing a weight-centric approach when treating T2DM.

Conclusion

Considering the high prevalence and debilitating complication of T2DM, it is of utmost importance to shift from a weight gain approach (i.e., insulin, sulfonylureas) into a weight loss/neutral one (i.e., GLP-1 agonists, SGLT-2 inhibitors, metformin).

Slow and Steady Wins the Race: 25 Years Developing the GLP-1 Receptor as an Effective Target for Weight Loss

Recent evidence from clinical trials supports the efficacy and tolerability of glucagon-like peptide 1 (GLP-1) receptor agonists as useful agents for weight loss. Although originally developed as glucose lowering agents for people with type 2 diabetes, progress in research over the last 3 decades has demonstrated that GLP-1 receptor agonists act in the central nervous system to reduce food intake. This minireview summarizes key aspects of GLP-1 biology and the clinical studies supporting the utility of the GLP-1 receptor signaling system as a therapeutic target for weight loss.

Type 2 Diabetes Remission with Significant Weight Loss: Definition and Evidence-Based Interventions

Type 2 diabetes (T2D) has long been regarded as an incurable and chronic disease according to conventional management methods. Clinical and pathophysiological studies on the natural course of T2D have shown that blood glucose control worsens with an increase in the number of required anti-hyperglycemic agents, as β-cell function progressively declines over time. However, recent studies have shown remission of T2D after metabolic surgery, intensive lifestyle modification, or medications, raising the possibility that β-cell function may be preserved or the decline in β-cell function may even be reversible. The World Health Organization as well as the American Diabetes Association and the European Association for the Study of Diabetes recognize remission as an appropriate management aim. In the light of the state of evidence for T2D reversal, physicians need to be educated on treatment options to achieve T2D remission so that they can actively play a part in counseling patients who may wish to explore these approaches to their disease. This review will introduce each of these approaches, summarizing their beneficial effects, supporting evidence, degree of sustainability, and challenges to be addressed in the future.

Detección de Nuevas Tecnologías Sanitarias Para Mejorar el Control Metabólico de Pacientes Con Diabetes Tipo 2 Atendidos en el Programa de Salud Cardiovascular de Chile

OBJECTIVES

In Chile, > 900,000 people with type 2 diabetes mellitus (DM2) are controlled in the Cardiovascular Health Program (PSCV). Even though the PSCV includes a set of interventions for the control of patients with DM2, the results are still insufficient, generating a high human, economic, and social cost. This study aimed to identify and select new health technologies for the control of patients with DM2 not currently incorporated into the PSCV to be proposed as candidates for an economic evaluation in the Chilean context.

METHODS

For the identification of new health technologies, consultations with key informants and an umbrella review of updated scientific evidence were used as sources of information. In a second step, selection among those technologies was conducted based on the effectiveness of the intervention, target population, nature of the intervention, and international evidence of cost-effectiveness antecedents.

RESULTS

Key informants identified 12 candidate health technologies not currently incorporated into the PSCV. From the umbrella review, an additional 9 health technologies were identified that were not identified by the key informants. Of the 21 new health technologies identified, finally 8 health technologies were selected (structured group education, pedometer use, periodontal treatment, cognitive-behavioral therapy, telemonitoring, sitagliptin, canagliflozin, and insulin degludec).

CONCLUSIONS

The health technologies detected have a high potential to be studied through economic evaluations that allow guiding decision making around improving the health outcomes of patients with DM2 in Chile.

Duodenal Switch Combined with Systematic Post-operative Supplementation and Regular Patient Follow-up Results in Good Nutritional Outcomes

INTRODUCTION

The duodenal switch is the most effective bariatric surgical procedure. Due to technical demands of the surgery and concerns regarding high rates of post-operative nutritional sequelae, many surgeons remain hesitant to adopt this technique.

METHODS

Sixty-five patients undergoing duodenal switch surgery at our hospital between 2008 and 2015 were followed up for 5 years. All patients were provided with a thorough post-operative nutritional supplementation regimen. Nutritional deficiencies as evidenced by blood testing, excess body weight loss, and remission rates from type 2 diabetes, hypertension, and dyslipidaemia were studied.

RESULTS

The average excess body weight loss 5 years post-operatively was 62% ± 23.03%. Remission rates for type 2 diabetes, hypertension, and dyslipidaemia were 96%, 77% and 84% respectively. Patients achieved good nutritional outcomes. After 5 years, deficiencies in fat-soluble vitamins A and D occurred in 3.3% and 1.6% of patients respectively. The rate of ferritin deficiency at the 5-year post-operative mark was 19.4%. No predictors of nutritional deficiency were identified on univariate analysis.

CONCLUSION

Patients undergoing a duodenal switch achieve good long-term excess body weight loss and high obesity-related co-morbidity remission rates. The rates of post-operative nutritional deficiencies in patients who are subjected to a thorough post-operative nutritional supplementation regimen are lower than what was historically expected.

Not Control but Conquest: Strategies for the Remission of Type 2 Diabetes Mellitus

A durable normoglycemic state was observed in several studies that treated type 2 diabetes mellitus (T2DM) patients through metabolic surgery, intensive therapeutic intervention, or significant lifestyle modification, and it was confirmed that the functional β-cell mass was also restored to a normal level. Therefore, expert consensus introduced the concept of remission as a common term to express this phenomenon in 2009. Throughout this article, we introduce the recently updated consensus statement on the remission of T2DM in 2021 and share our perspective on the remission of diabetes. There is a need for more research on remission in Korea as well as in Western countries. Remission appears to be prompted by proactive treatment for hyperglycemia and significant weight loss prior to irreversible β-cell changes. T2DM is not a diagnosis for vulnerable individuals to helplessly accept. We attempt to explain how remission of T2DM can be achieved through a personalized approach. It may be necessary to change the concept of T2DM towards that of an urgent condition that requires rapid intervention rather than a chronic, progressive disease. We must grasp this paradigm shift in our understanding of T2DM for the benefit of our patients as endocrine experts.

Effects of bariatric surgery on cardiorespiratory fitness: A systematic review and meta-analysis

Although bariatric surgery (BS) is recognized as an effective strategy for body weight loss, its impact on cardiorespiratory fitness (CRF) is still unclear. We aimed to examine postoperative changes in CRF (VO_2max/peak ) and its relationship with weight loss among adults undergoing BS. We systematically searched the WoS, PubMed, MEDLINE, and Scopus databases. Observational and intervention studies were selected reporting the presurgery and postsurgery CRF, measured by breath-by-breath VO₂ or its estimation. Eleven articles (312 patients) revealed that BS leads to a reduction in absolute VO_2max/peak in the short term (effect size, ES = -0.539; 95%CI = -0.708, -0.369; p < 0.001), and those patients who suffered a more significant decrease in BMI after BS also had a greater loss of absolute VO_2max/peak . However, VO_2max/peak relative to body weight increased after surgery (ES = 0.658; 95%CI = 0.473, 0.842; p < 0.001). An insufficient number of studies were found investigating medium and long-term changes in CRF after BS. This study provides moderate-quality evidence that the weight loss induced by BS can reduce CRF in the short term, which represents a therapeutic target to optimize BS outcomes. More high-quality studies are needed to evaluate the impact of BS on VO_2max/peak in the short, medium, and long term including normalized values for fat-free mass.

The Effect of Pre-operative Exercise Intervention on Patient Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis

This systematic review aimed to assess the effect of a pre-operative exercise intervention on short- and long-term health and clinical outcomes for adult patients undergoing bariatric surgery (BS). We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), SPORTDiscus and reference lists of relevant papers, through March 2021. Five randomised controlled trials were included (n = 199 patients). Modest increases in cardiorespiratory fitness (VO_2max) were found at both pre-operative (0.73 mL kg^-1 min^-1, P ≤ 0.001) and maximum follow-up time points (0.98 mL kg^-1 min^-1, P ≤ 0.04). There was no significant effect of an exercise intervention on percentage total weight loss (%TWL). Pre-operative exercise can induce significant short- and long-term improvements in fitness in individuals with obesity. There is insufficient evidence to determine whether pre-operative training impacts other post-operative clinical outcomes.

Longitudinal study on the effect of surgical weight loss on beat-to-beat blood pressure variability in patients undergoing bariatric surgery: a study protocol

INTRODUCTION

Alterations in linear and non-linear parameters of beat-to-beat blood pressure variability (BPV) have been shown to predict disease prognosis and distinguish between risk categories in various pathological conditions, independently of average blood pressure levels. Obesity places subjects at elevated risk of vascular diseases, including hypertension, resulting in serious cardiac, respiratory and cerebral events. However, little is known about the status of vascular dynamics in obese and morbidly obese adults.

METHODS AND ANALYSIS

In this present quasi-experimental longitudinal study, changes in beat-to-beat BPV, using continuous, non-invasive blood pressure monitoring, in obese subjects undergoing bariatric surgery are characterised. The capacity of linear and non-linear measures of BPV to detect differences between hypertensive, prehypertensive and normotensive obese subjects prebariatric and postbariatric surgery are tested. Additionally, potential correlations between beat-to-beat BPV and age, body mass index, gender and comorbidities will be investigated. In parallel, the impact of the unsteady fluctuations of beat-to-beat blood pressure on the dynamic stresses imparted by blood flow on blood vessel walls will be explored. We expect to find altered BPV profiles in hypertensive and prehypertensive subjects as compared with normotensive subjects. We also expect to see differential normalisation in BPV profiles between hypertensive, prehypertensive and normotensive subjects over time.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Board at the American University of Beirut (IRB ID: BIO-2018-0040). Study results will be made available to the public through publications in peer-reviewed journals and conference papers and/or presentations.

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.

Comparative Effectiveness of Bariatric Surgeries in Patients with Type 2 Diabetes Mellitus and BMI ≥ 25 kg/m2: a Systematic Review and Network Meta-Analysis

PURPOSE

In patients with type 2 diabetes mellitus (T2DM), bariatric surgery appears to be more effective than medical treatment (MT) at improving glycaemic control and decreasing cardiovascular risk. However, long-term effectiveness has not been systematically assessed using randomised controlled trials. In this study, we aimed to systematically assess randomised controlled trials, with at least 5 years of follow-up, on bariatric surgery in patients with T2DM and BMI ≥ 25 kg/m², as well as to compare different bariatric procedures.

MATERIAL AND METHODS

PubMed, SCOPUS and Web of Science were searched. We performed a network meta-analysis to evaluate the comparative effectiveness of the different procedures and MT in terms of full T2DM remission, weight loss, complications and cardiometabolic biomarkers. The quality of evidence was assessed using the Cochrane Risk of Bias Tool and CINeMA.

RESULTS

We included 11 primary studies. Laparoscopic one-anastomosis gastric bypass (LOAGB) was found to be one of the most effective treatments for full remission of T2DM (I² = 0, inconsistency p value = 0.9223). Biliopancreatic diversion without duodenal switch was found to be more effective than laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding regarding percent total cholesterol and low-density lipoprotein change. Regarding percent high-density lipoprotein and weight change, all analysed surgical treatments were shown to be more effective than MT. The confidence rating in our results was overall moderate, but most studies had high risk of performance and detection bias.

CONCLUSION

Bariatric surgery seems to be effective for T2DM remission. LOAGB appears to be a good option in this context, and a possible alternative to laparoscopic duodenal switch, but the included primary studies in our review are not sufficiently powered to establish a more definitive conclusion. More studies with longer follow-up times are needed to comprehensively assess bariatric surgery in T2DM.

Energy-restricted interventions are effective for the remission of newly diagnosed type 2 diabetes: A systematic review of the evidence base

BACKGROUND

Type 2 diabetes (T2D) is a chronic, progressive disease. Caloric restriction and subsequent weight loss have been associated with both improvements and, in some cases, remission of T2D.

AIM

To systematically review the safety and effectiveness of calorie-restricted diets on weight change and the remission of T2D.

METHODS

Electronic databases were searched. Intervention trials including a calorie restriction, published between 2010 and 2020, evaluating the remission of T2D (HbA1c <6.5% without diabetes medication) were selected. Risk of bias was assessed.

RESULTS

Eight trials met inclusion criteria including four randomized controlled and four single-arm trials. Three controlled trials found greater remission in the calorie-restricted arm (p < 0.05). A recent diagnosis of diabetes was associated with higher remission rates (75%-80%) with an inverse association between duration of diabetes and rate of remission (r = -0.94). A higher level of remission was observed with greater calorie restriction in non-new diagnosis studies. Greater weight loss was associated with increasing rates of remission (r = 0.83). No reported adverse events led to withdrawal from trials. There was great heterogeneity in study design.

CONCLUSION

Remission rate of T2D achieved through calorie restriction is high and similar to that reported in the bariatric surgery literature. Remission should be the aim at diagnosis and calorie restriction could be used to achieve this. The target weight loss should be >10% body weight in people with obesity. More research is needed into the optimum level of calorie restriction and the support required for long-term remission. National guidelines should be updated to reflect recent evidence.

Progress in treatment of type 2 diabetes by bariatric surgery

The incidence of type 2 diabetes (T2D) is increasing at an alarming rate worldwide. Bariatric surgical procedures, such as the vertical sleeve gastrectomy and Roux-en-Y gastric bypass, are the most efficient approaches to obtain substantial and durable remission of T2D. The benefits of bariatric surgery are realized through the consequent increased satiety and alterations in gastrointestinal hormones, bile acids, and the intestinal microbiota. A comprehensive understanding of the mechanisms by which various bariatric surgical procedures exert their benefits on T2D could contribute to the design of better non-surgical treatments for T2D. In this review, we describe the classification and evolution of bariatric surgery and explore the multiple mechanisms underlying the effect of bariatric surgery on insulin resistance. Based upon our summarization of the current knowledge on the underlying mechanisms, we speculate that the gut might act as a new target for improving T2D. Our ultimate goal with this review is to provide a better understanding of T2D pathophysiology in order to support development of T2D treatments that are less invasive and more scalable.

The Effect of Laparoscopic Sleeve Gastrectomy on Glycemic Control in Type 2 Diabetic Patients

Introduction The prevalence of diabetes mellitus type II (T2DM) in Kuwait in 2013 was 23.09%, ranking ninth globally and second in the Middle East and North Africa (MENA) region. It's been frequently reported as a growing public health concern. Our retrospective study will focus on the effect of laparoscopic sleeve gastrectomy (LSG) on the glycemic control of T2DM. Methods From December 2012 to January 2014, 70 patients with T2DM underwent LSG during the study period. A retrospective patient file review was performed and a follow-up on participants was carried out in February 2014. Fasting plasma glucose (FPG) was taken pre- and post-operatively. Patients were followed up to monitor the change in diabetic medications in terms of quantity, type and dose. Results The mean reduction of FPG after surgery was 2.94+3.66 (P < 0.001) over a mean interval of eight days (range, 0-34 days). Immediate reduction in FPG was seen in 61 patients (87%), and the greatest reduction was seen in the age group <40 years. Diabetes remission was seen in 49 patients (70%), while 20 (29%) had reduction in medication. All patients underwent a safe surgical procedure. There were no conversions to open surgery and no significant complications or mortalities. Conclusions Our study shows that LSG procedure has an immediate positive effect on the glycemic control of T2DM, in addition to the long-term evidence of complete resolution of diabetes in most patients or improvement in glycemic control, which has further highlighted the positive outcome of LSG, diminishing morbidity, risk factors, co-morbidities and health-expenditure.

Remission of Type 2 Diabetes with Very Low-Calorie Diets-A Narrative Review

Very low-calorie diets (VLCD) are hypocaloric dietary regimens of approximately 400-800 kcal/day that result in 20-30% reductions in body weight, sometimes in just 12-16 weeks. A body of evidence demonstrates that adherence to VLCD in adults with type 2 diabetes (T2D) can result in marked improvements to glycemic control and even full T2D remission, challenging the convention that T2D is a lifelong disease. Although these data are promising, the majority of VLCD studies have focused on weight loss and not T2D remission as a primary endpoint. Moreover, there is a wide range of VLCD protocols and definitions of T2D remission used across these hypocaloric studies. Together the large degree of heterogeneity in VLCD studies, and how T2D remission is defined, leave many gaps in knowledge to efficacy and durability of VLCD approaches for T2D remission. This narrative review examines findings from a body of data from VLCD studies that specifically sought to investigate T2D remission, and discusses the efficacy of VLCD compared to other hypocaloric approaches, and who is likely to benefit from VLCD approaches for T2D remission.

Single-Anastomosis Duodenal Switch: Conceptual Difference between East and West

Single-anastomosis duodenal switch (SADS) has become increasingly popular. This review compared the conceptual difference between Eastern (SADS-E) and Western (SADS-W) countries. After searching for SADS through PubMed and high-impact journals, 19 articles with 2280 patients were included for analysis. We found SADS-W was reserved for patients with a high body mass index (BMI) without type 2 diabetes mellitus (T2DM). Surgeons performing SADS-W used larger bougies and preferred shorter common channels. However, SADS-E was mainly preferred in T2DM patients with a low BMI. SADS-E bypassed less bowel and used smaller bougies. The spectra of major postoperative complications, nutritional deficiencies, and gastrointestinal disorders were different between SADS-E and SADS-W. SADS-W yielded better weight loss and better T2DM remission than SADS-E. SADS are effective bariatric and metabolic procedures with promising therapeutic outcomes and acceptable safety.

Update on Metabolic Bariatric Surgery for Morbidly Obese Adolescents

Despite worldwide public attention and intense medical efforts, the prevalence of severe morbid obesity in children and adolescents is still rising. Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways leading to serious co-morbidities such as impaired glucose tolerance or even type 2 diabetes (T2D), dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and hyperuricemia. The management of severe childhood obesity requires a life-long multidisciplinary approach with a combination of lifestyle changes, nutrition, and medications. Standardized life-style intervention programs remain the first-line treatment for morbid obese children and adolescents, but unfortunately reveal limited long-term success. In such cases, metabolic bariatric surgery (MBS) has evolved from being a controversial issue to being included in distinct recommendations. According to the American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee, indications for bariatric surgery in adolescence must follow very strict criteria. Adolescents with class II obesity (BMI > 120% of the 95th percentile) and a diagnosed co-morbidity or with class III obesity (BMI ≥ 140% of the 95th percentile) should be considered for MBS. These interventions represent high-risk operations, and adolescents should be treated in specialized, multidisciplinary high-volume obesity centers with long-term follow-up programs. The Roux-en-Y gastric bypass (RYGB) remains the gold standard of all malabsorptive procedures. Laparoscopic sleeve gastrectomy (LSG), which the authors pioneered as a stand-alone procedure in morbidly obese adolescents in 2008, has become the most commonly performed operation in morbidly obese adolescents at present. Recent literature proves that MBS is safe and effective in morbidly obese adolescents. Mid-term data have revealed significant improvement or even resolution of major co-morbidities. Thus, MBS for the treatment of morbidly obese adolescents has evolved from being a controversial issue to being included in distinct recommendations by several medical societies as a therapeutic strategy to reduce severe co-morbidities potentially causing end-organ damage in adulthood.

Three-Year Outcomes of Sleeve Gastrectomy Plus Jejunojejunal Bypass: a Retrospective Case-Matched Study with Sleeve Gastrectomy and Gastric Bypass in Chinese Patients with BMI ≥35 kg/m2

BACKGROUND

Sleeve gastrectomy plus jejunojejunal bypass (SG+JJB) is a novel bariatric procedure. In this study, we compared the 3-year outcomes of SG+JJB to those of sleeve gastrectomy (SG) and gastric bypass (RYGB).

METHODS

This retrospective study included 113 patients (SG, N=31; RYGB, N=33; SG+JJB, N=49) with a preoperative BMI≥35 kg/m². Among them, 31 pairs of patients who underwent SG+JJB/SG and 33 pairs who underwent SG+JJB/RYGB were matched by sex, age (±2 years), and BMI (±2 kg/m²). Postoperative weight loss, diabetes remission, and patient complaints at the 3-year follow-up were compared.

RESULTS

SG+JJB yielded higher 3-year total weight loss (TWL) than SG alone (35.5±9.1% vs 31.5±7.3%, P=0.031) and equivalent 3-year %TWL to RYGB. The diabetes remission rate of SG+JJB was similar to that of SG or RYGB. SG+JJB resulted in a higher incidence of malodorous flatus than SG (25.8% vs 0, P<0.05). Compared to RYGB, SG+JJB resulted in a higher incidence of postoperative de novo gastroesophageal reflux disease (GERD) symptoms (30.3% vs 0, P<0.05).

CONCLUSIONS

In the present study, we found that SG+JJB yielded higher weight loss than SG and similar weight loss to RYGB at the 3-year follow-up. SG+JJB increased the risk of malodorous flatus compared to SG and de novo GERD symptoms compared to RYGB.

Systematic Review and Meta-Analysis of Randomised Controlled Trials Comparing Long-Term Outcomes of Roux-En-Y Gastric Bypass and Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) has overtaken Roux-En-Y gastric bypass (RYGB) as the most common bariatric procedure worldwide. However, there is little long-term data comparing the two procedures.

OBJECTIVES

We perform a systematic review and meta-analysis comparing 5-year outcomes of randomised controlled trials (RCTs) comparing RYGB and SG.

METHODS

Medline, Embase, The Cochrane Library, and NHS Evidence were searched for English language RCTs comparing RYGB with SG and assessed weight loss and/or comorbidity resolution at 5 years.

RESULTS

Five studies were included in the final analysis. Meta-analysis demonstrates a significantly greater percentage excess weight loss in patients undergoing RYGB compared with SG (65.7% vs 57.3%, p < 0.0001). Resolution of diabetes was seen in 37.4% and 27.5% after RYGB and SG respectively. There was no significant difference between RYGB and SG in rates of resolution or improvement of diabetes. Similarly, HbA1C levels were not significantly different between the two procedures. Resolution of dyslipidaemia was more common after RYGB (68.6% vs 55.2%, p = 0.0443). Remission of gastro-oesophageal reflux occurred in 60.4% in the RYGB group in contrast to 25.0% in the SG group (p = 0.002).

CONCLUSIONS

Both RYGB and SG result in sustained weight loss and comorbidity control at 5 years. RYGB resulted in greater %EWL, improved dyslipidaemia outcomes and a lower incidence of postoperative gastro-oesophageal reflux disease (GORD).

Effects of bariatric surgery on lipid-lipoprotein profile

Most patients with severe obesity will present some lipid-lipoprotein abnormalities. The atherogenic dyslipidemia associated with severe obesity is characterized by elevated fasting and postprandial triglyceride levels, low high-density lipoprotein cholesterol concentrations, and increased proportion of small and dense low-density lipoproteins. Bariatric surgery has been proven safe and successful in terms of long-term weight loss and improvement in obesity co-existing metabolic conditions including lipid-lipoprotein abnormalities. Nevertheless, bariatric surgery procedures are not all equivalent. We conducted a comprehensive critical analysis of the literature related to severe obesity, bariatric surgery and lipid-lipoprotein metabolism/profile. In this review, we described the metabolic impacts of different bariatric surgery procedures on the lipid-lipoprotein profile, and the mechanisms linking bariatric surgery and dyslipidemia remission based on recent epidemiological, clinical and preclinical studies. Further mechanistic studies are essential to assess the potential of bariatric/metabolic surgery in the management of lipid-lipoprotein abnormalities associated with severe obesity. Understanding the beneficial effects of various bariatric surgery procedures on the lipid-lipoprotein metabolism and profile may result in a wider acceptance of this strategy as a long-term metabolic treatment of lipid-lipoprotein abnormalities in severe obesity and help clinician to develop an individualized and optimal approach in the management of dyslipidemia associated with severe obesity. BRIEF SUMMARY: Abnormal lipid-lipoprotein profile is frequent in patients with severe obesity. Significant improvements in lipid-lipoprotein profile following bariatric surgery occur early in the postoperative period, prior to weight loss, and persists throughout the follow-up. The mechanisms that facilitate the remission of dyslipidemia after bariatric surgery, may involve positive effects on adipose tissue distribution/function, insulin sensitivity, liver fat content/function and lipid-lipoprotein metabolism.

Variables Associated with Short-Term Weight Loss in a Cohort of Patients with Morbid Obesity According to Age and Three Types of Bariatric Surgery

Background The percentage of excess weight lost (%EWL) after bariatric surgery (BS) shows great discrepancies from one individual to another. Objective To evaluate the %EWL one year after BS and to determine the existence of baseline biomarkers associated with weight loss. Methods We studied 329 patients with morbid obesity undergoing three types of BS (biliopancreatic diversion (BPD), Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)), depending on the %EWL one year after surgery: good responders (GR) (%EWL ≥ 50%) and non-responders (NR) (%EWL < 50%). Results The GR presented a higher percentage of change in anthropometric and biochemical variables compared to the NR group, even within each type of BS. There was a greater percentage of GR among those who underwent RYGB. The patients who underwent SG showed the lowest decrease in biochemical variables, both in GR and NR. Within the GR group, those with a lower age showed greater improvement compared to the other age groups. A %EWL ≥50% was negatively associated with the age and atherogenic index of plasma (AIP), and positively with the type of BS (RYGB). Conclusions The GR group was associated with lower age and AIP and undergoing RYGB. Additionally, those patients who underwent SG showed a lower metabolic improvement.

Comparative efficacy of bariatric surgery for type 2 diabetes mellitus: A protocol for systematic review and network meta-analysis

BACKGROUND

The comparative efficacy of bariatric surgical procedures for type 2 diabetes mellitus (T2DM) has not been completely elucidated. To investigate this question, we conduct a systematic review and network meta-analysis.

METHODS

The protocol followed preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) checklist. Two review authors will independently search the PubMed, Embase (Ovid), and the Cochrane Central Register of Controlled Trials databases. The primary outcome is T2DM remission. The secondary outcomes include BMI, HbA1c (%), and percentage excess weight loss (% EWL). Results from the network meta-analysis will be presented as summary relative effect sizes (WMD or RR) and relative 95% CIs for each possible pair of treatments. Outcomes will be combined based on different periods of follow-up (12 months, 36 months, and 60 months).

RESULTS

The results will provide useful information about the efficacy of bariatric surgical procedures in patients with T2DM.

CONCLUSION

The findings of the study will be disseminated through peer-reviewed journal.

INPLASY REGISTRATION NUMBER

INPLASY202050053.

Bariatric Surgery in Prior Solid Organ Transplantation Patients: Is Race a Predictor of Adverse Outcomes?

Purpose

Metabolic and bariatric surgery (MBS) is increasingly performed in patients with previous solid organ transplantation (PSOT). In addition, controversy remains about whether racial disparity in outcomes following MBS exists. Therefore, the aim of this analysis was to determine if race independently predicts outcomes in MBS patients with PSOT.

Materials and Methods

Patients with PSOT undergoing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were identified in the 2017 Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database. Patients were stratified by race (Black and White). Propensity score matching was utilized to adjust for multiple demographic variables. Multivariable logistic regression analyses were performed for overall and bariatric-related morbidity.

Results

Of 335 MBS patients with PSOT, 250 (75%) were white and 85 (25%) were black patents. Procedure-type and surgical approach (p > 0.1) were similarly distributed. Black patients were more likely (p < 0.05) to have hypertension dialysis-dependent chronic kidney disease, and be on chronic steroids). Mortality and morbidity were similar. Black patients had significantly (p < 0.05) higher rates of renal failure, pulmonary complications, and emergency department visits in unmatched analysis. After propensity score matching, 82 patients in each cohort were identified and were similar at baseline (p > 0.5). In the matched analysis, black patients had higher overall (17% vs. 10%, p = 0.12) and bariatric-related morbidity (14% vs. 7.2%, p = 0.05). In addition, black patients had significantly (p < 0.05) higher rates of postoperative pneumonias, progressive renal insufficiency, and emergency department visits. On multivariable regression analysis, black race did not independently predict overall or bariatric-related morbidity.

Conclusion

MBS in racial cohorts with PSOT is safe, with very low rates of overall morbidity and mortality. Black race trended toward increased postoperative morbidity. Larger cohort studies are needed to validate our findings.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-04813-9) contains supplementary material, which is available to authorized users.

GLP-1 Analogues as a Complementary Therapy in Patients after Metabolic Surgery: a Systematic Review and Qualitative Synthesis

The evidence is strong that bariatric surgery is superior to medical treatment in terms of weight loss and comorbidities in patients with severe obesity. However, a considerable part of patients presents with unsatisfactory response in the long term. It remains unclear whether postoperative administration of glucagon-like peptide-1 analogues can promote additional benefits. Therefore, a systematic review of the current literature on the management of postoperative GLP-1 analogue usage after metabolic surgery was performed. From 4663 identified articles, 6 met the inclusion criteria, but only one was a randomized controlled trial. The papers reviewed revealed that GLP-1 analogues may have beneficial effects on additional weight loss and T2D remission postoperatively. Thus, the use of GLP-1 analogues in addition to surgery promises good results concerning weight loss and improvements of comorbidities and can be used in patients with unsatisfactory results after bariatric surgery.

Comparison of the effect of Roux-en-Y gastric bypass and sleeve gastrectomy on remission of type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

Bariatric surgery is an effective treatment option for patients with type 2 diabetes mellitus (T2DM) and obesity. This study aims to compare the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on remission of T2DM. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies published between database inception and 21 November 2019. A meta-analysis, using a random effects model, was performed to calculate relative risk (RR) of T2DM remission between the groups in randomized controlled trials (RCTs). Of 2650 records identified, 12 records from 10 different RCTs were finally included. The studies comprised 705 patients with follow-up from 1 to 5 years. The remission rate of T2DM at 1 year was higher among those undergoing RYGB (156/276, 57%) compared with those undergoing SG (128/275, 47%), RR (95% CI) 1.20 (1.00-1.45), P = .047, I² = 24.9%, moderate-quality evidence. Among studies with 2- to 5-year follow-up, there was no difference in remission rates between the RYGB (132/263, 50%) and SG (121/266, 46%) groups, RR 1.06 (0.94-1.20), P = .34, I² = 0.0%, low-quality evidence. RYGB resulted in a higher rate of T2DM remission compared with SG after 1 year. The T2DM remission rates did not differ in studies with 2- to 5-year follow-up.

Energy Balance and Weight Loss for Diabetes Remission

Diabetes remission-the occurrence of durable normoglycemia without antidiabetic medications-has been demonstrated in some patients with type 2 diabetes who have achieved and sustained weight loss through lifestyle intervention or metabolic and bariatric surgery. Although this pursuit would represent a paradigm shift in our diabetes chronic care model, could diabetes remission become a routine treatment strategy in patients with type 2 diabetes? This article reviews the mechanisms by which weight loss can drive improvements in insulin sensitivity and β-cell function sufficient to normalize glycemia, treatment approaches that provide evidence for diabetes remission, and avenues for developing the research and discovery that will be required to make diabetes remission possible as part of the routine medical management of type 2 diabetes.

First Successful Large-Scale Introduction of an Enhanced Recovery after Bariatric Surgery (ERABS) Program in the Middle East: The Results and Lessons Learned of Tawam Hospital/Johns Hopkins, a Tertiary Governmental Center in the UAE

BACKGROUND

Although enhanced recovery after bariatric surgery (ERABS) has proven to be safe and cost-effective, this concept is relatively new in the Middle East.

METHODS

A retrospective analysis of consecutive registered cohorts of patients who underwent primary and purely laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) were compared before introduction of ERABS (2010-2014) and after ERABS (2015-2017) at Tawam Hospital/Johns Hopkins, the UAE.

RESULTS

A total of 462 eligible bariatric patients (LSG 414 and LRYGB 48) were operated on before and 1602 (LSG 1436 and LRYGB 166) after introduction of the ERABS. Significant improvements of mean patient time of the patient being within the OR for LSG (from 2:27 to 1:23 min, p = 0.000) and LRYGB (from 3:17 to 1:59 min, p = 0.000) were achieved when comparing pre-ERABS with after introduction of ERABS. Furthermore, there was a significant decrease in LOS in both LSG (from 3.2 to 1.5 days, p = 0.000) and in LRYGB (from 3.5 to 1.7 days, p = 0.000). Major (CD classification III-IV) complications decreased significantly in LSG (from 13.8 to 0.8%, p = 0.000) and were similar in LRYGB (from 4.2% to 3.0%, p = NS). The readmission rate for LSG (from 2.9 to 2.6%, p = NS) or LRYGB (from 0 to 4.8%, p = NS) and the reoperation rates after LSG (from 0.7 to 0.5%, p = NS) and LRYGB (from 0 to 2.4%, p = NS) did not differ between both groups following introduction of ERABS.

CONCLUSIONS

Implementation of a standardized ERABS program in the Middle East is feasible and safe and leads to reduced LOS and OR times.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures.

METHODS

A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement.

RESULTS

The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members.

CONCLUSIONS

Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

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

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.