Technical feasibility and safety profile of laparoscopic diverted sleeve gastrectomy with ileal transposition (DSIT)

Diet Management of Patients with Chronic Kidney Disease in Bariatric Surgery

Morbid obesity is considered a civilization disease of the 21st century. Not only does obesity increase mortality, but it is also the most important cause of the shortening life expectancy in the modern world. Obesity is associated with many metabolic abnormalities: dyslipidemia, hyperglycemia, cardiovascular diseases, and others. An increasing number of patients diagnosed with chronic kidney disease (CKD) are obese. Numerous additional disorders associated with impaired kidney function make it difficult to conduct slimming therapy and may also be associated with a greater number of complications than in people with normal kidney function. Currently available treatments for obesity include lifestyle modification, pharmacotherapy, and bariatric surgery (BS). There are no precise recommendations on how to reduce excess body weight in patients with CKD treated conservatively, undergoing chronic dialysis, or after kidney transplantation. The aim of this study was to analyze studies on the bariatric treatment of obesity in this group of people, as well as to compare the recommendations typical for bariatrics and CKD.

Innovative Bariatric Procedures and Ethics in Bariatric Surgery: the IFSO Position Statement

With the rise in obesity and bariatric procedures worldwide, there has been a surge in new and innovative procedures that has been increasingly offered to patients. In this position statement, IFSO highlights the importance of surgical ethics in innovation and when offering new procedures. Furthermore, the task force reviewed the current literature to describe which procedures can be offered as mainstream outside research protocols versus those that are still investigational and need further data.

Metabolic Effects of Sleeve Gastrectomy with Transit Bipartition in Obese Females with Type 2 Diabetes Mellitus: Results After 1-Year Follow-up

PURPOSE

To present the early metabolic effects of sleeve gastrectomy with transit bipartition (SG + TB) procedure in female obese patients with type 2 diabetes mellitus (T2DM).

METHODS

This prospective clinical study was carried out between January 2016 and June 2017. Inclusion criteria were female participants under 60 years old with T2DM, body mass index ≥ 40 kg/m² and HbA1c level ≥ 8%. All patients underwent to SG + TB procedure. Primary outcomes were the glycemic control variables, and the secondary outcomes were weight loss and dyslipidemia levels up to the last follow-up point.

RESULTS

A total of 35 female participants with an average age of 48.8 ± 6.0 years old and a mean preoperative BMI of 42.0 ± 1.3 kg/m² were included during the study period. Diabetic remission was achieved in 88.6% of patients (n = 31) on the third month without any antidiabetic medications. The mean postoperative BMI of patients was 24.8 ± 1.6 kg/m², and dyslipidemia levels were significiantly lower at the last follow-up point of all patients.

CONCLUSIONS

SG + TB procedure may be a potent therapeutic option for the treatment of obese patients with T2DM.

Cardiac remodeling in obesity and after bariatric and metabolic surgery; is there a role for gastro-intestinal hormones?

Introduction: Obesity is associated with various diseases such as type 2 diabetes, hypertension, obstructive sleep apnea syndrome (OSAS), metabolic syndrome, and cardiovascular diseases. It affects several organ systems, including the pulmonary and cardiac systems. Furthermore, it induces pulmonary and cardiac changes that can result in right and/or left heart failure.Areas covered: In this review, authors provide an overview of obesity and cardiovascular remodeling, the individual actions of the gut hormones (like GLP-1 and PYY), the effects after bariatric/metabolic surgery and its influence on cardiac remodeling. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date until April 2019), regarding cardiac function changes before and after bariatric surgery and literature regarding changes in gastrointestinal hormones.Expert opinion: Regarding the surgical treatment of obesity and metabolic diseases there is recognition of the importance of both weight loss (bariatric surgery) and improvement in metabolic milieu (metabolic surgery). A growing body of evidence further suggests that bariatric surgical procedures [like the Sleeve Gastrectomy (SG), Roux-en Y Gastric Bypass (RYGB), or One Anastomosis Gastric Bypass (OAGB)] have can improve outcomes of patients suffering from a number of cardiovascular diseases, including heart failure.

Ileal interposition coupled with duodenal diverted sleeve gastrectomy versus standard medical treatment in type 2 diabetes mellitus obese patients: long-term results of a case-control study

BACKGROUND

Randomized controlled trials have demonstrated that bariatric surgery is effective in obtaining remission of type 2 diabetes mellitus (T2DM) in obese patients, yet no data exist in the literature from prospective studies with ileal interposition with duodenal diversion sleeve gastrectomy (II-DD-SG). The aim of this case-control study is to investigate if II-DD-SG is superior to medical treatment in T2DM obese patients.

METHODS

Thirty obese patients (BMI > 30) affected by T2DM were recruited for surgery (II-DD-SG) between 2008 and 2011 and were matched with an equal control group which received standard medical treatment. Anthropometric measures, glucose metabolism, cardiovascular risk factors were determined baseline and during follow-up. The primary end point was T2DM remission; reduction of body weight, BMI, and cardiovascular risk factors were secondary end-points.

RESULTS

Shortly after II-DD-SG, normalization of glucose plasma levels and glycated hemoglobin was observed followed by a significant decrease in body weight and BMI. At one-year follow-up, insulin resistance strongly declined as did insulin plasma levels. Complete remission was observed in 26 patients (86%); 2 (6.6%) had partial remission, and two (6.6%) were still diabetic. After 5 years, 17 of 25 patients on follow-up (68%) showed complete remission of T2DM and 56% had remission of cardiovascular risk factors. Only two patients receiving medical treatment showed complete remission of T2DM (p < 0.0001 versus II-DD-SG). No significant changes of anthropometric parameters and lipid metabolism were recorded.

CONCLUSIONS

II-DD-SG is an effective surgical procedure, able to induce complete and prolonged remission of T2DM in obese patients as opposed to medical treatment.

Laparoscopic Ileal Interposition with Diverted Sleeve Gastrectomy Versus Laparoscopic Transit Bipartition with Sleeve Gastrectomy for Better Glycemic Outcomes in T2DM Patients

BACKGROUND

Metabolic procedures provide better outcomes for obese patients with type 2 diabetes mellitus. Our aim was to compare the glycemic regulation in patients that have undergone the laparoscopic ileal interposition with diverted sleeve gastrectomy (II-DSG), laparoscopic transit bipartition with sleeve gastrectomy (TB-SG), and laparoscopic sleeve gastrectomy (LSG) throughout a 12-month follow-up period retrospectively.

METHODS

This study considered patients with T2DM who underwent metabolic procedures. The postoperative changes in the glucose, C-peptide, HbA1c, HOMA-IR, insulin, cholesterol, body mass index, and total weight loss (TWL) were compared retrospectively. The intended outcome was to reach a long lasting fasting blood glucose (FBG) <126 mg/dl. A multivariate regression analysis was applied to define the predictive markers in glucose regulation.

RESULTS

Present study consisted of 83 patients with a mean age of 47.25 ± 6.58 years, mean preoperative BMI of 37.36 ± 2.71 kg/m², and mean outcomes in the HbA1C and FBG of 9.05 ± 1.33% and 237 ± 15 mg/dl, respectively. There were similar correlations in BMI and total weight loss (TWL). At 12-month follow up period, compared to LSG group, TB-SG and II-DSG groups have higher remission proportions (35.3, 67.9, 54.7, respectively, p < 0.05) with similar TWL% (22.35, 27.14, 23.16%) outcomes. The II-DSG and TB-SG results drew closer together toward the end of this study interval unlike the LSG group.

CONCLUSION

Our results showed that II-DSG and TB-SG ensured significant regression rates during the follow-up period. Since the TB-SG achieved these outcomes by finite anastomoses and intervening segments, it was considered to be a superior procedure compared to II-DSG and LSG procedures.

Ileal Transposition Surgery Decreases Fat Mass and Improves Glucose Metabolism in Diabetic GK Rats: Possible Involvement of FGF21

Objective: Ileal transposition (IT) surgery has been reported to improve glucose and lipid metabolism, and fibroblast growth factor 21 (FGF21) is a powerful metabolic regulator. In the present study, we aimed to investigate the effects of IT surgery on metabolism and its possible relationship with the FGF21 signaling pathway in diabetic Goto-Kakizaki (GK) rats. Methods: Ten-week-old male GK rats were subjected to IT surgery with translocation of a 10 cm ileal segment to the proximal jejunum (IT group) or sham surgery without the ileum transposition (Sham-IT group). Rats in the no surgery group did not receive any surgical intervention. Six weeks later, body weight, fat mass, fasting blood glucose (FBG), and serum levels of FGF21 and leptin were measured. The expression of the FGF21 signaling pathway and white adipose tissue (WAT) browning-related genes in the WAT and liver were evaluated by real-time reverse transcription polymerase chain reaction (RT-qPCR) and western blot. Results: IT surgery significantly decreased the body weights and FBG levels and increased the insulin sensitivity of GK rats. The total WAT mass of the IT rats showed a 41.5% reduction compared with the Sham-IT rats, and serum levels of FGF21 and leptin of the IT rats decreased by 26.3 and 61.7%, respectively (all P < 0.05). The mRNA levels of fibroblast growth factor receptor 1 (FGFR1) and its co-receptor β klotho (KLB) in the perirenal WAT (pWAT) of the IT rats were 1.4- and 2.4-fold that of the Sham-IT rats, respectively, and the FGFR1 protein levels were 1.7-fold of the Sham-IT rats (all P < 0.05). In accordance with the pWAT, the protein levels of FGFR1 and KLB in the epididymal WAT (eWAT) of the IT rats notably increased to 3.0- and 3.9-fold of the Sham-IT rats (P < 0.05). Furthermore, uncoupling protein 1 (UCP1) protein levels in the eWAT and pWAT of the IT rats also increased to 2.2- and 2.3-fold of the Sham-IT rats (P < 0.05). However, the protein levels of FGFR1 and KLB in the subcutaneous WAT (sWAT) of the IT rats decreased by 34.4 and 72.1%, respectively, compared with the Sham-IT rats (P < 0.05). In addition, the protein levels of FGF21 and KLB in the livers of IT rats were 3.9- and 2.3-fold of the Sham-IT rats (all P < 0.05). Conclusions: IT surgery significantly decreased fat mass and improved glucose metabolism in diabetic GK rats. These beneficial roles of IT surgery were probably associated with its stimulatory action on the expression of FGFR1 and KLB in both the eWAT and the pWAT, thereby promoting UCP1 expression in these tissues.

Time to Glycemic Control - an Observational Study of 3 Different Operations

BACKGROUND

Medical treatment fails to provide adequate control for many obese patients with type 2 diabetes mellitus (T2DM). A comparative observational study of bariatric procedures was performed to investigate the time at which patients achieve glycemic control within the first 30 postoperative days following sleeve gastrectomy (SG), mini-gastric bypass (MGB), and diverted sleeve gastrectomy with ileal transposition (DSIT).

METHODS

Included patients had a body mass index (BMI) ≥30 kg/m²; T2DM for ≥3 years, HbA_1C > 7 % for ≥3 months, and no significant weight change (>3 %) within the prior 3 months. Surgical procedures performed were SG (n = 49), MGB (n = 93), and DSIT (n = 109). The primary endpoint was the day within the first postoperative month on which mean fasting capillary glucose levels reached <126 mg/dL. Multivariate logistic regression analysis was used to identify predictors of glycemic control.

RESULTS

The cohort included 251 patients with a mean BMI of 36.04 ± 5.76 kg/m²; age, 52.84 ± 8.52 years; T2DM duration, 13.09 ± 7.54 years; HbA_1C, 8.82 ± 1.58 %. On the morning of surgery, mean fasting plasma glucose was 177.63 ± 51.3 mg/dL; on day 30, 131.35 ± 28.7 mg/dL (p < 0.05). Mean fasting plasma glucose of <126 mg/dL was reached in the DSIT group (124.36 ± 20.21 mg/dL) on day 29, and in the MGB group (123.61 ± 22.51 mg/dL), on day 30. The SG group did not achieve target mean capillary glucose level within postoperative 30 days.

CONCLUSION

During the first postoperative month, glycemic control (<126 mg/dL) was achieved following DSIT and MGB, but not SG. Preoperative BMI and postprandial C-peptide levels were independent predictors of early glycemic control following DSIT.

The impact of laparoscopic diverted sleeve gastrectomy with ileal transposition (DSIT) on short term diabetic medication costs

Background

Type 2 diabetes mellitus (T2DM) has gained pandemic proportions becoming a global threat within the last few decades. In parallel to the increasing prevalence, healthcare costs have become a huge economic burden for the hospital and governments. Bariatric surgery has been proven to induce glycemic control in obese type 2 diabetics. However, the cost effectiveness of metabolic surgery in overweight, obese and morbidly obese individuals has not been documented. We aimed to demonstrate the efficacy and reduced diabetic-medication cost after diverted sleeve gastrectomy with ileal interposition (DSIT) in type 2 diabetic individuals followed more than 1 year.

Methods

Records of 116 type 2 diabetic patients operated by DSIT at a dedicated metabolic surgery clinic between October 2011 and April 2013 were retrospectively reviewed. A comparison was made between the annual diabetic medication cost before and after surgery using the paired t test. The alterations in BMI and HbA1c were recorded and analyzed.

Results

Diverted sleeve gastrectomy with ileal interposition led to a marked reduction in BMI and improved glycemic control after 1 year follow-up. Mean HbA1c levels decreased from a mean of 8.9 ± 1.7 to 6.6 ± 1.1 1 year after surgery (p < 0.001). Mean preoperative BMI declined from 32.9 ± 4.3  to 24.7 ± 2.7 kg/m² (p < 0.001). Cost of diabetic medication decreased from a mean 660.08 USD/year to 65.12 USD 1 year after surgery (p < 0.001).

Conclusion

Our results have shown that DSIT operation leads to a significantly better glycemic control and lower diabetic medication costs at 1 year.