The Effect and Predictive Score of Gastric Bypass and Sleeve Gastrectomy on Type 2 Diabetes Mellitus Patients with BMI < 30 kg/m(2)

Preoperative contributing factors and the remission of diabetes after metabolic surgery: the mediating role of preoperative triglyceride

BACKGROUND AND OBJECTIVE

Limited understanding exists regarding the factors affecting the prognosis of surgical treatment for type 2 diabetes mellitus (T2DM), particularly in Chinese patients. In this study, we examined a cohort of early and intermediate obese T2DM patients to explore the potential impact of preoperative lipid metabolism in metabolic surgery on the postoperative remission of T2DM.

METHODS

Participants with T2DM and obesity underwent metabolic surgery. Clinical data, including baseline body mass index, percentage of excess weight loss, and preoperative biochemical indicators, were collected and analyzed. A multidisciplinary team conducted patient follow-up. Remission was defined as sub-diabetic hyperglycemia (HbA1c < 48 mmol/mol, fasting glucose 100-125 mg/dl) without pharmacological intervention for at least 12 months.

RESULTS

Over a median follow-up of 27 months, 96 T2DM patients with metabolic surgery were studied, with no laparotomies required. Among these patients, 61 (63.5%) achieved complete remission, and 85 (88.5%) experienced remission. In multivariable analysis models, preoperative fasting blood glucose (FBG) significantly correlated with all postoperative outcomes. Furthermore, mediation analysis indicated that preoperative triglycerides (TG) mediated 26.31% of the association between preoperative FBG and postoperative remission. Both preoperative FBG and TG were negatively associated with the postoperative remission of T2DM.

CONCLUSION

In summary, our findings suggest that lower preoperative fasting glucose levels enhance the likelihood of postoperative T2DM remission. Moreover, preoperative TG could potentially play a mediating role in the postoperative remission of T2DM. Therefore, evaluating and managing fasting glucose and lipids before the procedure may aid in assessing the prognosis of metabolic surgery. Level of evidence Level III, designed cohort.

Metabolic Surgery in Korea

Metabolic surgery (MS) is a surgery that focuses on improving obesity-related comorbidities. It is often referred to as "diabetic surgery" because of its focus on treating type 2 diabetes. MS is distinguished from bariatric surgery (BS), in which weight loss is the primary goal. However, from a broader perspective, all surgeries for obese patients with diabetes can be considered MS. In Korea, metabolic and bariatric surgery (MBS) has been covered by the national health insurance since 2019. Patients with a body mass index (BMI) ≥35 or those with a BMI ≥30 and obesity-related comorbidities were eligible for MBS. Simultaneously, MS for patients with BMI values between 27.5 and 30 was partly reimbursed. The two major metabolic surgeries are Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). According to the registry of the Korean Society of Metabolic and Bariatric Surgery, 1,560 metabolic surgeries for obese patients with diabetes were performed between 2019 and 2021 in Korea, which was approximately 35.6% of all bariatric surgeries. SG was the most common, followed by RYGB and duodenal switch surgery. When dividing the patients with diabetes who underwent MBS into two groups, specifically those with BMI <35 and ≥35, we found that SG was performed most common procedure in both groups. However, there was a higher proportion of RYGB and duodenal switch operation in the former, indicating a difference in surgical methods between the two groups. MS is a promising tool for the management of poorly controlled diabetes. More data are needed to establish proper patient selection and choice of surgical type.

Safety and Efficacy of Metabolic Surgery in Patients with Type 2 Diabetes in the Middle East and North Africa Region: An Analysis of Primary Roux-en-Y Gastric Bypass and Sleeve Gastrectomy Outcomes

INTRODUCTION

Type 2 diabetes (T2D) is a chronic medical condition that results in significant health implications and reduced life expectancy. The International Diabetes Federation (IDF) estimated that in 2021, 51.8% of all deaths of people under 60 years old in the Middle East and North Africa (MENA) region were related to diabetes. Bariatric surgery has been demonstrated to be a safe and effective treatment for T2D in different populations worldwide, though few specific data exist on outcomes of procedures in the MENA region. The aim of this study was to compare the safety and postoperative outcomes between patients with and without T2D undergoing primary bariatric surgery at a tertiary referral academic medical center in the United Arab Emirates.

METHODS

All patients who underwent primary metabolic surgery between September 2015 and July 2020 were retrospectively reviewed from a prospective database. Group 1 included patients with T2D, and Group 2 included patients without T2D. Patients undergoing revisional or correctional operations were excluded. The procedure performed was based on surgeon discretion in discussion with a multidisciplinary team and the patient. Demographics as well as perioperative and postoperative results were examined.

RESULTS

Our study included 542 patients, 160 (29.5%) with T2D and 382 (70.5%) with non-T2D. Mean age was 44.5 years (range 16-70) in the T2D group and 33.3 years (range 15-63) in the non-T2D group; median BMI was 41.8 ± 7.3 and 43.2 ± 7.2, respectively. The T2D group was 37.5% male and 62.5% female, and the non-T2D group was 38.7% male and 61.3% female. There were no significant differences in comorbidities. In the T2D group, 45.6% of patients underwent Roux-en-Y gastric bypass and 54.4% sleeve gastrectomy. In the non-TD2 group, 42.7% of patients received Roux-en-Y gastric bypass and 57.3% sleeve gastrectomy. There were no statistically significant differences in postoperative ED visits (21.8% vs. 24.3%, p = 0.21), minor complications within 30 days (4.3% vs. 5.2%, p = 0.67), readmission rates (5.6% vs. 4.9%, p = 0.77), re-operation rates (3.7% vs. 1.5%, p = 0.11), median hospital stay (2.0 days vs. 3.0, p = 0.05), or complications after 30 days (6.2% vs. 11.2%, p = 0.07). There were no deaths either group.

CONCLUSIONS

In this cohort of patients from the MENA region, bariatric surgery in T2D patients is safe and effective, with perioperative outcomes comparable to those of non-T2D patients. To the best of our knowledge, our postoperative findings, which are the first report in the MENA region, are consistent with studies published in North America and Europe.

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.

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.

Diabetes Resolution at 10 Years After Biliopancreatic Diversion in Overweight and Class 1 Obese Patients with Type 2 Diabetes

Background

Long-term anti-diabetic effects of BPD in overweight or class 1 obese T2DM patients were investigated reporting the results at 10 years after BPD performed in severely non-obese T2DM patients.

Material and Methods

Thirty T2DM patients with BMI lower than 35 kg/m² were investigated at 1, 5, and 10 years after BPD, and the results are compared with those of 30 T2DM patients followed for 10 years on pharmacological and/or behavioral conventional therapy.

Results

Mean levels of fasting blood glucose (FBG) and serum glycated hemoglobin (HbA1_C) showed a marked reduction 1 year after BPD, values remaining slightly above the diabetic range throughout the entire follow-up. T2DM remission was observed in about 50% of the cases at 5 and 10 years after the operation. In 16 patients (53%), severe BPD-related complications developed, in ten cases requiring a surgical revision of the operation. In the BPD group, one patient died for malignant lymphoma and two patients after surgical revision. Within the control group, during the 10-year follow-up, no changes in the diabetic status were observed, being the FBG and HbA1_C mean values higher than those recorded in the BPD patients at any follow-up time. All T2DM subjects of the control group were alive at the end of the 10-year follow-up.

Conclusion

Despite satisfactory long-term metabolic outcomes, these data indicate that BPD should be used with caution as a metabolic procedure in the treatment of T2DM in overweight or class 1obese patients.

Graphical abstract

Validation of Ad-DiaRem and ABCD Diabetes Remission Prediction Scores at 1-Year After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in the Randomized Controlled Oseberg Trial

BACKGROUND

Prediction of type 2 diabetes (T2DM) remission is an important part of risk-benefit assessment before bariatric surgery.

STUDY DESIGN

Advanced-DiaRem (Ad-DiaRem) and ABCD diabetes remission scores for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were calculated using baseline data. Differences in model discrimination using area under the curve of receiver operating curve (AUC-ROC) and model calibration were tested for complete remission (HbA1c ≤ 6.0% without antidiabetic medications) in the two groups. Optimal cutoff scores were calculated using the Youden index.

RESULTS

We randomized 109 patients to either SG or RYGB. With one patient lost to follow-up in each group, the scores were calculated for 54 patients in the SG group and 53 patients in the RYGB group. Both models showed moderate predictive power without any significant difference between the groups: AUC-ROCs (95% CI) for the Ad-DiaRem score (SG versus RYGB) were 0.872 (0.780-0.964) versus 0.843 (0.733-0.954), p = 0.69, and for the ABCD score 0.849 (0.752-0.946) versus 0.750 (0.580-0.920), p = 0.32, respectively. Using optimal cutoff points derived from the whole study population, the actual proportion of diabetes remission was significantly higher than predicted for both the Ad-DiaRem and ABCD scores in the RYGB group. Diabetes duration and glycated haemoglobin predicted diabetes remission in the entire Oseberg population.

CONCLUSION

Both the Ad-DiaRem and ABCD scores showed moderate ability to discriminate between those who achieved remission of T2DM and those who did not after SG and RYGB. Larger studies are needed for the identification of procedure-specific optimal cutoffs. Trial Registration ClinicalTrials.gov Identifier: NCT01778738.

Effect of bariatric surgery versus medical therapy on long-term cardiovascular risk in low BMI Chinese patients with type 2 diabetes: a propensity score-matched analysis

BACKGROUND

Reducing the risk of death due to cardiovascular disease (CVD) is an important direction for diabetes prevention and treatment. The Chinese population with type 2 diabetes (T2D) has a high risk of developing CVD at relatively low body mass index (BMI) levels. Currently, no studies have evaluated the effect of bariatric surgery versus medical therapy on long-term CVD risk in patients with T2D and low BMI.

OBJECTIVES

To compare bariatric surgery versus medical therapy for long-term CVD risk in Chinese patients with T2D and low BMI by using the China Prediction for ASCVD Risk equations and the United Kingdom Prospective Diabetes Study risk engine.

SETTING

University hospital, China.

METHODS

Medical records of patients with T2D with a BMI <35 kg/m² undergoing bariatric surgery or medical therapy from May 2010 to December 2018 were reviewed. A 1:1 propensity score matching was performed by using 7 preoperative characteristics. Variables for calculating CVD risk scores over the 5-year follow-up were assessed.

RESULTS

A total of 684 patients with T2D underwent bariatric surgery (n = 75) or medical therapy (n = 609), and 52 pairs of matched subjects were selected from both groups after propensity score matching. The 10-year and lifetime atherosclerotic CVD risk by using the China Prediction for ASCVD Risk equation at 5 years follow-up period in the bariatric surgery group improved significantly compared with the medical therapy group. In the fifth year of follow-up, the 10-year risk of coronary heart disease, fatal coronary heart disease, stroke, and fatal stroke by using the United Kingdom Prospective Diabetes Study risk engine were much lower in the bariatric surgery group than in the medical therapy group (10.37 ± 5.64% versus 27.25 ± 7.28%, P = .004; 6.3 ± 4.5% versus 22.3 ± 7.35%, P = .002; 4.97 ± 3.73% versus 15.05 ± 3.63%, P = .001; .59 ± .45% versus 1.52 ± .14%, P < .001. respectively). The use of glucose-lowering medications, including insulin, was reduced from baseline in both groups, and patients in the bariatric surgery group required significantly fewer of these medications than those in the medical therapy group.

CONCLUSION

Bariatric surgery in patients with T2D and low BMI conferred a lower calculated risk of CVD compared with medical therapy over 5 years of follow-up.

Prognostic Models for Predicting Remission of Diabetes Following Bariatric Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Remission of type 2 diabetes following bariatric surgery is well established, but identifying patients who will go into remission is challenging.

PURPOSE

To perform a systematic review of currently available diabetes remission prediction models, compare their performance, and evaluate their applicability in clinical settings.

DATA SOURCES

A comprehensive systematic literature search of MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) was undertaken. The search was restricted to studies published in the last 15 years and in the English language.

STUDY SELECTION

All studies developing or validating a prediction model for diabetes remission in adults after bariatric surgery were included.

DATA EXTRACTION

The search identified 4,165 references, of which 38 were included for data extraction. We identified 16 model development and 22 validation studies.

DATA SYNTHESIS

Of the 16 model development studies, 11 developed scoring systems and 5 proposed logistic regression models. In model development studies, 10 models showed excellent discrimination with area under the receiver operating characteristic curve ≥0.800. Two of these prediction models, ABCD and DiaRem, were widely externally validated in different populations, in a variety of bariatric procedures, and for both short- and long-term diabetes remission. Newer prediction models showed excellent discrimination in test studies, but external validation was limited.

LIMITATIONS

While the key messages were consistent, a large proportion of the studies were conducted in small cohorts of patients with short duration of follow-up.

CONCLUSIONS

Among the prediction models identified, the ABCD and DiaRem models were the most widely validated and showed acceptable to excellent discrimination. More studies validating newer models and focusing on long-term diabetes remission are needed.

Is Bariatric Surgery Effective for Chinese Patients with Type 2 Diabetes Mellitus and Body Mass Index < 35 kg/m2? A Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery has been applied for weight loss and comorbidity control in China since 2000. Recent studies have shown positive results for bariatric surgery in patients with a body mass index (BMI) of less than 35 kg/m². However, the effect of surgery on Chinese patients with type II diabetes mellitus (T2DM) has not yet been systematically investigated.

METHODS

A comprehensive literature search was performed in the Cochrane Library, Embase, PubMed, and Web of Science from January 2014 to March 2020. All studies examined bariatric surgery outcomes on Chinese patients at 12-, 36-, and 60-month follow-up. The research followed the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) recommendations.

RESULTS

Eleven studies containing 611 patients were included in this meta-analysis. Clinical indices at 12-, 36-, and 60-month follow-up were analyzed. Significant decreases were identified in body weight, BMI, waist circumference (WC), blood pressure (BP), fasting plasma glucose (FPG), glycosylated hemoglobin A1c (hemoglobin A1c, or HbA1c), triglyceride (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) postoperatively. An increasing trend in the T2DM remission rate was discovered. The remission group was observed to have significantly lower HbA1c and C-peptide level, a shorter duration of T2DM, and a higher BMI than the nonremission group at 12 months.

CONCLUSIONS

Bariatric surgery successfully provided significant BMI control as well as a reduction and normalization of glucose- and lipid-related metabolism at 12, 36, and 60 months postoperatively in Chinese patients with T2DM with a preoperative BMI of less than 35 kg/m². An increasing trend in the T2DM remission rate suggested promising future applications in this population.

Long-term outcomes of metabolic surgery in overweight and obese patients with type 2 diabetes in Asia

AIM

To assess the outcomes of metabolic surgery in overweight and obese patients in Asia with type 2 diabetes (T2D).

MATERIALS AND METHODS

The treatment outcomes of 1999 patients from the Asian Diabetes Surgery Summit database were analysed. The changes in treatment effects across time were assessed with respect to the surgical procedures performed by using generalized estimating equations.

RESULTS

The most commonly performed procedure was the single-anastomosis gastric bypass (32.6%). Weight (from 106.2 ± 25.1 to 77.9 ± 18.8 kg), body mass index (BMI; from 38.7 ± 7.9 to 28.5 ± 5.9 kg/m² ), blood sugar (from 9.3 ± 4.1 to 5.7 ± 1.8 mmol/L) and HbA1c (from 8.4% ± 1.8% to 6.0% ± 1.1%) significantly improved from baseline to 1 year (P < .001) and remained stable at 5 years (weight, 86.3 ± 23.3 kg; BMI, 31.7 ± 7.9 kg/m² ; blood sugar, 5.8 ± 1.8 mmol/L, and HbA1c, 6.4% ± 1.2%; all P < .001 vs. baseline). Blood pressure and most lipid disorders also improved significantly. Of the treatment procedures, single-anastomosis gastric bypass had the most satisfactory outcomes with statistical significance for most disorders, whereas adjustable gastric banding displayed the least satisfactory outcomes.

CONCLUSIONS

Metabolic surgery remarkably improved body weight, T2D and other metabolic disorders in Asian patients. However, the efficacy of individual procedures varied substantially.

Metabolomic Profiles Predict Diabetes Remission after Bariatric Surgery

Background: Amino acid metabolites (AAMs) have been linked to glucose homeostasis and type 2 diabetes (T2D). We investigated whether (1) baseline AAMs predict T2D remission 12 months after bariatric surgery and (2) whether AAMs are superior for predicting T2D remission postoperatively compared with existing prediction models. Methods: Among 24 participants undergoing bariatric surgery, 16 diabetes-related AAMs were quantified at baseline and postoperative 3 and 12 months. Existing prediction models included the ABCD, DiaRem, and IMS models. Results: Baseline L-dihydroxyphenylalanine (L-DOPA) (areas under receiver operating characteristic curves (AUROC), 0.92; 95% confidence interval (CI), 0.75 to 1.00) and 3-hydroxyanthranilic acid (3-HAA) (AUROC, 0.85; 95% CI, 0.67 to 1.00) better predicted T2D remission 12 months postoperatively than the ABCD model (AUROC, 0.81; 95% CI, 0.54 to 1.00), which presented the highest AUROC value among the three models. The superior prognostic performance of L-DOPA (AUROC at 3 months, 0.97; 95% CI, 0.91 to 1.00) and 3-HAA (AUROC at 3 months, 0.86; 95% CI, 0.63 to 1.00) continued until 3 months postoperatively. Conclusions: The AAM profile predicts T2D remission after bariatric surgery more effectively than the existing prediction models.

Impact of metabolic surgery on 10-year cardiovascular disease risk in Chinese individuals with type 2 diabetes

BACKGROUND

In recent years, many reports have highlighted that metabolic surgery may ameliorate the cardiovascular risk in morbidly obese patients with or without type 2 diabetes (T2D). However, few studies have evaluated the long-term cardiovascular disease (CVD) risk after metabolic surgery in T2D patients with a low body mass index (BMI).

OBJECTIVES

To use the Prediction for ASCVD Risk in China (China-PAR) equations and United Kingdom Prospective Diabetes Study (UKPDS) risk engine to assess the 10-year CVD risk in low-BMI T2D patients after metabolic surgery.

SETTING

University hospital, China.

METHODS

We retrospectively reviewed our prospectively collected data of T2D patients who underwent metabolic surgery at our hospital between 2010 and 2018. We included patients who met the criteria for calculating a 10-year cardiovascular risk score by the China-PAR equations and UKPDS risk engine. Demographic characteristics, anthropometric variables, and glycolipid metabolic parameters were assessed preoperatively and during a 4-year follow-up period. Patients with a BMI < 30 kg/m² were compared with those with a BMI > 30 kg/m².

RESULTS

We evaluated 117 patients, of whom 62 (53%) had a BMI < 30 kg/m² and 55 (47%) had a BMI > 30 kg/m². Patients with a BMI < 30 kg/m² were significantly older and had a longer duration of diabetes. The rate of complete T2D remission in the group of patients with BMIs < 30 kg/m² was significantly lower than that in the group with BMIs > 30 kg/m² (35.2% versus 56.1%, respectively; P = .042). The overall 10-year and lifetime atherosclerotic cardiovascular disease risks were reduced from 4.2% to 2.3% and 25.3% to 13.9%, respectively (both P < .05), at 1 year postoperatively using the China-PAR equation. The overall 10-year coronary heart disease (CHD) and fatal CHD risks were reduced by 48.1% and 53.1%, respectively, at 1 year after surgery using the UKPDS risk engine. The advantages of metabolic surgery in reducing CVD risks are similar in both BMI groups, whether using the China-PAR equation or the UKPDS risk engine.

CONCLUSION

The 10-year CVD risk in T2D patients with BMIs < 30 kg/m² and BMIs > 30 kg/m² were significantly reduced after metabolic surgery, although the rate of complete T2D remission T2Din patients with BMIs < 30 kg/m² was lower than that in patients with BMIs > 30 kg/m². The China-PAR equation is a reliable and useful clinical tool for CVD risk evaluation in Chinese patients after metabolic surgery.

One Anastomosis Gastric Bypass for the Treatment of Type 2 Diabetes: Long-Term Results and Recurrence

BACKGROUND

Bariatric/metabolic surgery has been incorporated into the therapeutic treatment of type 2 diabetes mellitus (T2DM). Among many bariatric/metabolic procedures, one anastomosis gastric bypass (OAGB) is one of the most effective procedures but long-term data about T2DM recurrence after OAGB are lacking.

METHODS

Outcomes of 134 patients who had undergone OAGB for the treatment of T2DM with long-term (5 years) follow-up were assessed in a retrospective cohort study. The remission of T2DM after OAGB surgery was evaluated in different groups using a scoring system composed of the age, BMI, C-peptide level, duration of T2DM (ABCD score), and percent of total weight loss (%TWL).

RESULTS

The %TWL and percent of excess weight loss (%EWL) of the OAGB patients at 5 years after surgery were 29.2 (10.6) and 72.1(27.5), respectively. The mean BMI decreased from 39.5(7.9) to 27.6(5.3) kg/m² and mean glycated hemoglobin A1C (HbA1c) decreased from 8.9 to 5.9% in OAGB patients at 5 years after OAGB. The complete T2DM remission rate of OAGB was 76.1% at 1 year and 64.2% at 5 years after surgery. Forty-one (57.8%) out of 71 patients who completed a 10-year follow-up remained in complete T2DM remission. The T2DM recurrence rate of OAGB patients was 15.7% at 5 years after surgery.

CONCLUSIONS

OAGB is highly effective in inducing T2DM remission but a significant number of patients will still have T2DM recurrence. To select patient with an ABCD score > 5 and maintaining a weight loss greater than 30% is important for durable T2DM remission after OAGB.

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.

[Therapeutic effect of laparoscopic Roux-en-Y gastric bypass in non-obese patients with type 2 diabetes]

OBJECTIVE

To evaluate the effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery for treatment of type 2 diabetes (T₂D) in patients with a body mass index (BMI) &lt; 27.5 kg/m².

METHODS

We retrospectively analyzed the data of patients who underwent LRYGB surgery from March, 2012 to June, 2018 in the General Hospital of Guangzhou Military Command and Jinshazhou Hospital of Guangzhou University of Chinese Medicine. The changes in the parameters of glucose metabolism and physical indicators of the patients in the first, second and third years after the surgery were analyzed in patients in low BMI group and high BMI group.

RESULTS

All the 74 patients underwent LRYGB successfully without conversion to open surgery. One year after the surgery, fasting blood glucose (FBG), HbA1c, postprandial blood glucose, fasting insulin, HOMA-IR, fasting C-peptide, BMI, body weight and waistline were significantly improved compared with their preoperative values in low BMI group (P &lt; 0.05). At 2 years after the operation, FBG, HbA1c, postprandial blood glucose, HOMA-IR, BMI, body weight and waistline were significantly improved compared with the preoperative values in low BMI group (P &lt; 0.05). In the third year, FBG, HOMA-IR, fasting C-peptide, body weight and waistline were significantly improved compared with the preoperative values in low BMI group (P &lt; 0.05). There was no significant difference in the parameters of glucose metabolism and islet function between low BMI group and high BMI group at different stages. No serious complications occurred in these patients after the surgery.

CONCLUSIONS

LRYGB is effective for treatment of T2D in Chinese patients with a BMI &lt; 27.5. After the surgery, the patient show reduced waistline without significant weight loss. The long-term results of the surgery still require further investigations with a larger samples and longer follow-up.

Analysis of Predictors of Type 2 Diabetes Mellitus Remission After Roux-en-Y Gastric Bypass in 101 Chinese Patients

BACKGROUND

To investigate prognostic factors for complete remission in type 2 diabetes mellitus (T2DM) patients who underwent gastric bypass (GBP) and to establish a prognostic model for risk stratification.

METHODS

We evaluated the baseline clinical features of patients with T2DM who received at Beijing Tian Tan Hospital from April 2012 to December 2015. Complete remission of T2DM was defined as meeting the following criteria: HbA1c < 6.5%, fasting plasma glucose (FPG) < 100 mg/dL, and absence of hypoglycemic drugs for 1 year following GBP.

RESULTS

A total of 101 patients were enrolled in our study, and the complete remission rate of T2DM was 70.3% (71/101). Compared with patients with incomplete remission, patients with complete remission of T2DM had higher C-peptide levels, lower HbA1c, shorter disease duration, better β cell function, and an absence of insulin therapy. HbA1c level, fasting C-peptide, duration of T2DM, and history of medical therapy were important prognostic factors for complete remission of T2DM (P = 0.001, 0.002, 0.01, 0.028, respectively). Patients with HbA1c lower than 7.5%, a history of T2DM shorter than 9.5 years, fasting C-peptide higher than 1.2 ng/mL, and absence of insulin therapy before GBP achieved a higher complete remission rate of T2DM after GBP (AUC of the model was 0.825, 95% CI, 0.741-0.910; P = 0.001).

CONCLUSIONS

The duration of T2DM, history of medical therapy, and levels of HbA1c and fasting C-peptide are independent predictors for the prognosis of T2DM patients undergoing GBP. Patients with HbA1c lower than 7.5%, a history of T2DM shorter than 9.5 years, a fasting C-peptide higher than 1.2 ng/mL, and an absence of insulin therapy may have a higher complete remission rate of T2DM after GBP.

Discordance in prediction for prognosis of type 2 diabetes after metabolic surgery: comparison of the ABCD, DiaRem, and individualized metabolic surgery models

PURPOSE

Metabolic surgery has been performed as a treatment option for uncontrolled type 2 diabetes (T2D), and several scoring systems for predicting postoperative T2D remission have been proposed. This study was designed to assess consistency of 3 existing scoring systems in patients with T2D duration <1 year.

METHODS

This study included 186 patients with T2D enrolled in a university hospital prospective database between 2011 and 2013. Externally validated scoring systems for predicting T2D prognosis after metabolic surgery were identified and selected through systematic literature search. We assessed concordance between ABCD, DiaRem, and individualized metabolic surgery (IMS) scores in participants using kappa statistical analysis and 1-way analysis of variance.

RESULTS

Of the participants, 52 and 82 patients were expected to have favorable T2D remission after metabolic surgery with ABCD score of 10-5 and DiaRem score of 0-7, respectively, and a slight-to-fair concordance was shown between the 2 scoring systems (kappa measure, 0.07; standard error [SE], 0.05 and kappa measure, 0.25; SE, 0.19, respectively). The DiaRem score increased with T2D severity determined by IMS score (P < 0.001), while the ABCD score showed no significant association with IMS score.

CONCLUSION

ABCD and DiaRem scores showed significant discordance when applied to potential metabolic surgery candidates in whom postoperative T2D remission rate was highly expected. The IMS score showed a dose-response association with DiaRem score but had no significant association with the ABCD score.

Does Metabolic Surgery Lead to Diabetes Remission in Patients with BMI < 30 kg/m2?: a Meta-analysis

BACKGROUND

Bariatric surgery has demonstrated to be effective in remission of type 2 diabetes in obese patients, but it is unclear in non-obese patients. The aim of this study is to investigate if metabolic surgery is effective in diabetes resolution in patients with BMI < 30 kg/m².

MATERIALS AND METHODS

A systematic review was performed and the content of the PubMed, Ovid, and the Cochrane Library databases covering the period January 2008 to April 2018 was searched. Studies with metabolic surgery performed in patients with type 2 diabetes, BMI < 30 kg/m² and a follow-up ≥ 6 months were included. Type 2 diabetes remission rate and metabolic parameters changes were measured. A meta-analysis was conducted with the selected studies.

RESULTS

Twenty-six studies were included in the meta-analysis (1105 patients). The mixed-effects meta-analysis model for overall diabetes remission rate produced an estimate of 43% (95% IC 34-53%, p < 0.001). Moderator effects of the variables race, preoperative HbA1c, BMI, months of follow-up, duration of diabetes, and age on diabetes remission were also assessed, with no significant effects being found in any of them. A reduction in BMI (- 3.57 kg/m²), fasting blood glucose (- 55.93 mg/dL) and HbA1c (- 2.08%) was observed after surgery.

CONCLUSIONS

Metabolic surgery could be effective in remission of type 2 diabetes in BMI < 30 kg/m² patients but randomized and long-term studies are necessary. The scientific community should agree in a single definition of type 2 diabetes remission, in order to know the real effect of metabolic surgery in this group of patients.

Predicting remission of diabetes post metabolic surgery: a comparison of ABCD, diarem, and DRS scores

BACKGROUND

Obesity is one of the major causes for development of T2DM. Metabolic surgery has been proved to be a successful and cost-effective treatment modality for managing the patients with obesity and T2DM. Many scoring systems and models have been described in literature to predict the outcome of T2DM after metabolic surgery. The aim of this study is to compare the efficacy of Diarem, DRS, and ABCD score in predicting the T2DM remission.

METHODS

A total number of 102 diabetic patients, who underwent LMGB/LOAGB, were selected for this study. A retrospective analysis of the three scoring systems when applied to these patients and their predictive abilities were analyzed.

RESULTS

At 1 year after surgery, 72 (70.59%) patients achieved remission of T2DM. Though the pairwise comparisons between AUC on ROC analysis of ABCD, Diarem, and DRS scores does not show statistically significant difference between them, Diarem score has the maximum relative area under ROC curves. By multivariate analysis, it was found that factors significantly associated with T2DM remission were duration of T2DM, C-peptide, and Pre-Op HbA1c.

CONCLUSIONS

Among the three scoring systems, though DiaRem score has the best sensitivity and specificity and maximum AUC, no statistically significant difference was found in their diabetes remission predicting abilities. A shorter duration of T2DM, a lower HbA1C, and higher levels of C-peptide were significantly associated with a higher chance of T2DM remission.

Prediction of Type 2 Diabetes Remission after Bariatric or Metabolic Surgery

Bariatric surgery has evolved from a surgical measure for treating morbid obesity to an epochal remedy for treating metabolic syndrome as a whole, which is represented by type 2 diabetes mellitus. Numerous clinical trials have advocated bariatric or metabolic surgery over nonsurgical interventions because of markedly superior metabolic outcomes in morbidly obese patients who satisfy traditional criteria for bariatric surgery (body mass index [BMI] >35 kg/m2) and in less obese or simply overweight patients. Nevertheless, not all diabetes patients achieve the most desirable outcomes; i.e., diabetes remission after metabolic surgery. Thus, candidates for metabolic surgery should be carefully selected based on comprehensive preoperative assessments of the risk-benefit ratio. Predictors for diabetes remission after metabolic surgery may be classified into two groups based on mechanism of action. The first is indices for preserved pancreatic beta-cell function, including younger age, shorter duration of diabetes, and higher C-peptide level. The second is the potential for an insulin resistance reduction, including higher baseline BMI and visceral fat area. Several prediction models for diabetes remission have been suggested by merging these two to guide the joint decision-making process between clinicians and patients. Three such models, DiaRem, ABCD, and individualized metabolic surgery scores, provide an intuitive scoring system and have been validated in an independent external cohort and can be utilized in routine clinical practice. These prediction models need further validation in various ethnicities to ensure universal applicability.

Effects of Laparoscopic Roux-en-Y Gastric Bypass for Type 2 Diabetes Mellitus: Comparison of BMI > 30 and < 30 kg/m2

Background

Recently, many studies focused on type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) < 30 kg/m² and suggested that those patients might benefit from Roux-en-Y gastric bypass (RYGB). However, evidence on its effectiveness to improve T2DM patients with BMI < 30 kg/m² is still lacking. The aim of this study is to explore whether T2DM patients with BMI < 30 kg/m² get similar surgical effect from RYGB compared with those patients with BMI > 30 kg/m².

Methodology

Seventy patients with uncontrolled T2DM underwent laparoscopic RYGB from May 2010 to December 2015 in the GI Department of Daping Hospital. Weight, BMI, waist circumference, glucose, and lipid metabolic parameters were collected and evaluated at baseline and 1, 3, 6, 12, and 24 months postsurgery. Patients with BMI < 30 kg/m² were compared with those with BMI > 30 kg/m².

Results

Among the 70 patients, 47 (67.1%) BMI < 30 kg/m², and 23 (32.9%) BMI > 30 kg/m². Patients with BMI < 30 kg/m² are significantly older; they are female predominant and have longer duration of diabetes. The complete remission of T2DM was 28.2% of the BMI < 30 kg/m² group and 57.9% of the BMI > 30 kg/m² group (p = 0.029). There was no significant difference in the change of glucose and lipid metabolic parameters of both groups. FPG, 2hPG, and HbA1c% levels were significantly improved after 1 month (p < 0.05), and then remained essentially stable from the sixth month in both groups.

Conclusions

The 2-year study has shown that RYGB is a safe and effective procedure in treating T2DM with BMI < 30 kg/m², although the complete remission of T2DM in the BMI < 30 kg/m² group is lower than the BMI > 30 kg/m² group.

Do Bariatric Surgery-Related Type 2 Diabetes Remission Predictors Add Clinical Value? A Study on Asian Indian Obese Diabetics

BACKGROUND

Bariatric surgery has emerged to be the most effective treatment strategy for the treatment of obesity and type 2 diabetes mellitus (T2DM) achieving high remission rates. Many factors have been evaluated with a potential to predict the improvement of glycemic control following bariatric procedures. This study aims to study the various predictive factors for T2DM and the ABCD score in obese diabetic patients undergoing bariatric surgery in a South Indian population.

METHODS

A total of 53 obese patients (BMI > 30 k/m²) with T2DM who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LGB) from March 2014 to March 2015 were selected for the study. The patients were followed up to study the effects of various predictors of T2DM remission at 1 year.

RESULTS

Out of the 53 patients, 35 (66%) underwent LSG and 18 (34%) underwent LGB. Patients (81.1%) had T2DM remission. Mean HbA1c values decreased from 8.07 ± 1.98 to 6.0 ± 0.71. Only higher pre-operative body weight (p = 0.04) and lower HbA1c level (p = 0.04) were significantly associated with T2DM remission. Higher absolute weight loss (p = 0.03) after surgery was also significantly associated with T2DM remission. ABCD score was not significantly associated with T2DM remission although patients with ABCD score higher than 7 demonstrated 100% remission rate.

CONCLUSION

Among all the factors, only higher pre-operative weight and better glycaemic control along with better post-operative weight loss were significantly associated with the remission of T2DM. Although not significantly associated with remission of T2DM, higher ABCD scores had higher likelihood of remission.

The effect of metabolic surgery on nonobese patients (BMI<30 kg/m2) with type 2 diabetes: a systematic review

BACKGROUND

The influence of metabolic surgery on the glucose and lipid profiles of nonobese body mass index<30 kg/m² patients with type 2 diabetes, particularly the effect ≥1 year, remains unknown.

METHODS

PubMed and Ovid Embase were used.

SETTING

University hospitals.

RESULTS

In total, 21 studies including 921 patients were examined in this systematic review, the results of which revealed decrease in body mass index, waist circumference, fasting plasma glucose, glycosylated hemoglobin A1C, fasting C-peptide, fasting insulin, homeostasis model of assessment for insulin resistance index, triglycerides, total cholesterol, and low-density lipoprotein cholesterol. An increase in high-density lipoprotein cholesterol was also observed. The diabetes remission rates ranged from 13.3% to 90.2% according to 20 studies. The incidence of gastrointestinal bleeding ranged from 1% to 10% according to 9 studies. Four studies reported anemia after Roux-en-Y gastric bypass or one-anastomosis gastric bypass, with the incidence ranging from 8% to 33%.

CONCLUSIONS

Nonobese patients can achieve improvements in weight-related indices and glucose and lipid profiles in the short and medium term after metabolic surgery; however, the complications of metabolic surgery warrant further attention.

Impact of biliopancreatic limb length on severe protein-calorie malnutrition requiring revisional surgery after one anastomosis (mini) gastric bypass

Background:

One anastomosis (mini) gastric bypass (OAGB) is believed to be more malabsorptive than Roux-en-Y gastric bypass. A number of patients undergoing this procedure suffer from severe protein–calorie malnutrition requiring revisional surgery. The purpose of this study was to find the magnitude of severe protein–calorie malnutrition requiring revisional surgery after OAGB and any potential relationship with biliopancreatic limb (BPL) length.

Methods:

A questionnaire-based survey was carried out on the surgeons performing OAGB. Data were further corroborated with the published scientific literature.

Results:

A total of 118 surgeons from thirty countries reported experience with 47,364 OAGB procedures. Overall, 0.37% (138/36,952) of patients needed revisional surgery for malnutrition. The highest percentage of 0.51% (120/23,277) was recorded with formulae using >200 cm of BPL for some patients, and lowest rate of 0% was seen with 150 cm BPL. These data were corroborated by published scientific literature, which has a record of 50 (0.56%) patients needing surgical revision for severe malnutrition after OAGB.

Conclusions:

A very small number of OAGB patients need surgical correction for severe protein–calorie malnutrition. Highest rates of 0.6% were seen in the hands of surgeons using BPL length of >250 cm for some of their patients, and the lowest rate of 0% was seen with BPL of 150 cm. Future studies are needed to examine the efficacy of a standardised BPL length of 150 cm with OAGB.

The Mechanism of Metabolic Surgery: Gastric Center Hypothesis

BACKGROUND

There is growing evidence that bariatric surgery can lead to remission of metabolic syndrome. But the mechanism by which bariatric surgery alleviates metabolic syndrome is unclear.

MATERIALS AND METHODS

Several present hypotheses which include decreased caloric intake following the surgeries, foregut and hindgut hypothesis, bile acid and bacterial flora changes, and proposed gastric center hypothesis were discussed.

RESULTS

None of the currently available hypotheses is solely capable to lead to a reasonable explanation regarding improvement of metabolic syndrome by various bariatric surgical procedures. Proposed gastric center hypothesis could give a better explanation of the mechanism.

CONCLUSIONS

All the present bariatric surgeries are involved in changes of the stomach. There could be some particular cells on the stomach, which could secrete unknown special hormones, and then lead to control the metabolic process.

Preoperative Prediction of Type 2 Diabetes Remission After Gastric Bypass Surgery: a Comparison of DiaRem Scores and ABCD Scores

BACKGROUND

Gastric bypass surgery has been well accepted as a novel treatment modality for type 2 diabetes mellitus (T2DM) in obese patients. Some scoring systems have been proposed for the selection of T2DM patients who are eligible for gastric bypass surgery. This study compares two scoring systems with regard to remission of T2DM after gastric bypass surgery.

METHODS

This retrospective cohort study included 245 patients (150 females and 95 males) who had undergone gastric bypass surgery for the treatment of T2DM with 1 year follow-up. We examined the predictive power of complete remission of two scoring systems, the DiaRem score, and the ABCD score. The DiaRem score includes the factors of age, HbA1c, medication, and insulin usage. The ABCD score includes the factors of age, BMI, C-peptide level, and duration of T2DM. The rate of remission of T2DM after gastric bypass surgery was evaluated using both scoring systems.

RESULTS

At 1 year after surgery, the percent weight loss was 26.5 % and the mean BMI decreased from 35.7 to 26.2 kg/m(2). The mean HbA1c decreased from 8.8 to 6.2 %. A significant number of patients showed improvement in glycemic control, including 130 (53.1 %) patients with complete remission (HbA1c < 6.0 %), 36 (14.7 %) patients with partial remission (HbA1c < 6.5 %), and 26 (10.6 %) patients with improvement (HbA1c < 7 %). Both the DiaRem score and the ABCD score predicted the success of the gastric bypass surgery, but the ABCD score was better at differentiating patients with poorer score (27.9 vs. 9.1 %, p < 0.001).

CONCLUSIONS

Gastric bypass surgery is a treatment option for obese T2DM patients. The ABCD score is better at predicting T2DM remission at 1 year after gastric bypass surgery than the DiaRem score.

PRELIMINARY ANALYSIS OF INTERLEUKIN-6 CHANGES IN PRE- AND POSTOPERATIVE IN DIABETIC PATIENTS WITH BMI<35 SUBMITTED TO PARTIAL DUODENAL SWITCH

Background:

Studies related to obesity have shown association with metabolic syndrome. Data showing that obesity is capable to cause low grade chronic inflammation, without its classic signs and symptoms, call attention to researches to study different cells types and the mechanism of the inflammatory process.

Aim:

To evaluate the variation of glycated hemoglobin (HbA1c) and the pro-inflammatory cytokine interleukin-6 (IL6) in diabetic patients with BMI <35 kg/m² in the pre and postoperative of partial duodenal switch.

Method:

Nine patients were studied before and one year after the operation and the variation of the serum IL6 was measured by Elisa. The changes of HbA1c were also registered.

Results:

The pre-operative IL6 levels reached 65,50436±2,911993 pg/ml and one year after de operation 39,47739±3,410057 and the HbA1c average of 10,67 and 5.8 in the same period.

Conclusion:

The partial duodenal switch was efficient to control one year after the procedure the chronic inflammatory process caused by the diabetes mellitus type 2 with BMI <35 by dropping the IL6 levels and bringing the HbA1c to normal.

Sleeve gastrectomy activates the GLP-1 pathway in pancreatic β cells and promotes GLP-1-expressing cells differentiation in the intestinal tract

Db/db mouse was used to study the underlying mechanisms by which Sleeve gastrectomy (SG) improves β-cell function. We investigated β-cell function, plasma active GLP-1 levels, the GLP-1R pathway in β cells and L cell differentiation. After SG, β-cell function was significantly increased, and the GLP-1R-PKCζ-PDX-1 pathway was active in β cells. Plasma active GLP-1 levels, as well as the number of L cells in the jejunum, were significantly increased after SG. The expression of early transcription factors (TF), including Ngn3, FoxA1 and Nkx2.2, was not compromised by chronic hyperglycemia. In contrast, the expression of the downstream TF PAX6 was affected, and this down-regulation could be reversed by SG. So, SG can maintain L cell differentiation, increase plasma active GLP-1 level, sustain the activation of the GLP-1R pathway and improve β cell function in Db/db mice. Our results show that SG can overall improve the function of the entero-insular axis.

Systematic review of risk prediction models for diabetes after bariatric surgery

BACKGROUND

Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery.

METHODS

A systematic literature review was performed in MEDLINE, MEDLINE-In-Process, Embase and the Cochrane Central Register of Controlled Trials databases in April 2015. All English-language full-text published derivation and validation studies for risk prediction models on diabetic outcomes after bariatric surgery were included. Data extraction included population, outcomes, variables, intervention, model discrimination and calibration.

RESULTS

Of 2330 studies retrieved, eight met the inclusion criteria. Of these, six presented development of risk prediction models and two reported validation of existing models. All included models were developed to predict diabetes remission. Internal validation using tenfold validation was reported for one model. Two models (ABCD score and DiaRem score) had external validation using independent patient cohorts with diabetes remission assessed at 12 and 14 months respectively. Of the 11 cohorts included in the eight studies, calibration was not reported in any cohort, and discrimination was reported in two.

CONCLUSION

A variety of models are available for predicting risk of diabetes following bariatric surgery, but only two have undergone external validation.

Surgery for type 2 diabetes: the case for Roux-en-Y gastric bypass

The Roux-en-Y gastric bypass (RYGB) has traditionally been the most common bariatric procedure. Long-term data on the efficacy of RYGB demonstrate a long-lasting benefit in weight loss and control of the metabolic syndrome. Although observations of type 2 diabetes (T2D) resolution after RYGB have been reported for 3 decades, it was not until recently that multiple randomized trials comparing RYGB to medical therapy verified the same thing: RYGB leads to significantly greater diabetes control and remission. Even though T2D can relapse, there remains a significant overall benefit of bariatric surgery regarding the downstream effects of T2D: cardiovascular risk and micro- and macrovascular complications. Limited data are available on the comparative effectiveness of RYGB and sleeve gastrectomy in improving glucose homeostasis, but studies including both surgical procedures suggest that the benefit of RYGB in T2D may be more profound. Although further research is needed to examine closely any differences between these 2 procedures, multiple studies underscore the unprecedented value of bariatric surgery for the control and remission of T2D.

Type 2 diabetes remission following gastric bypass: does diarem stand the test of time?

OBJECTIVE(S)

Roux-en-Y Gastric Bypass (RYGB) is well known to ameliorate type 2 diabetes mellitus (T2DM), and recent work suggests that the preoperative DiaREM model predicts successful remission up to 1 year post-RYGB. However, no data exist for long-term validity. Therefore, we sought to determine the utility of this score on long-term RYGB effectiveness for T2DM resolution at 2 and 10 years, respectively.

METHODS

T2DM patients (Age: 48, BMI: 49, HbA_1C: 8.1) undergoing RYGB at the University of Virginia between 2004-2006 (n = 42) and 2012-2014 (n = 59) were evaluated prospectively to assess preoperative DiaREM score, defined from insulin use, age, HbA_1C, and type of antidiabetic medication. T2DM partial remission status was based on the American Diabetes Association guidelines (HbA_1C < 6.5 % and fasting glycemia <125 mg/dL, and no anti-diabetic medications). Chi-square test was used to compare patient's T2DM status to their DiaREM probability of remission.

RESULTS

Among RYGB patients with 2-year postoperative data, 2 were lost (n = 1 no follow-up and n = 1 died) resulting in 57 patients for analysis. For the 10-year postoperative data, 11 were lost (n = 6 no follow-up and n = 5 died), thereby resulting in only 31 patients for analysis. Patients were distributed by DiaREM score to correlate with the predicted probability of remission as follows: 0-2 (Predicted 94 %, 2-year 100 % p = 0.61, 10-year 100 % p = 0.72), 3-7 (Predicted 76 %, 2-year 94 % p = 0.08, 10-year 83 % p = 0.57), 8-12 (Predicted 36 %, 2-year 47 % p = 0.38, 10-year 43 % p = 0.72), 13-17 (Predicted 22 %, 2-year 20 % p = 0.92, 10-year 33 % p = 0.64), and 18-22 (Predicted 9 %, 2-year 15 % p = 0.40, 10-year 14 % p = 0.64).

CONCLUSIONS

Preoperative DiaREM scores are a good tool for predicting both short- and long-term T2DM remissions following RYGB. This study highlights the need to identify strategies that improve T2DM remission in those at highest risk.