The Recovery of Beta-Cell Function is Critical for Antidiabetic Outcomes of Gastric Bypass in Asian Subjects with Type 2 Diabetes and a Body Mass Index Below 30

Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS)

The 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for metabolic and bariatric surgery (MBS), replacing the previous guidelines established by the National Institutes of Health (NIH) over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams (MDTs), as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

The Metabolic Effects and Effectiveness of the Different Reconstruction Methods used in Gastric Cancer Surgery: A Systematic Review and Meta-Analysis

Gastric Cancer (GC) is the fifth most common cancer worldwide. Early stages of GC began being detected, giving rise to a new concern, Quality of Life. This study aimed to systematically assess the effects of different GC reconstruction techniques on postoperative type 2 diabetes mellitus (T2DM), hypertension (HBP), and body mass index (BMI) reduction rate and to provide an overview of recent research on oncometabolic surgery (OS). We performed a systematic review and meta-analysis by searching three databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed a meta-analysis of risk ratios and mean differences to estimate the impact of duodenal bypass, Roux-en-Y reconstruction, and residual stomach on T2DM, HBP, and BMI reduction rate. Heterogeneity was assessed using the I2 statistics. At the end of the follow-up, the duodenal bypass group compared to Billroth I had a significantly higher postoperative remission of T2DM and HBP, with a relative risk (RR) of 1.43 (95% confidence interval (95% CI) [1.27; 1.62]) and 1.3 (95% CI [1.00; 1.69]), respectively. Compared with the Billroth II group, Roux-en-Y reconstruction had significantly greater T2DM remission after gastrectomy (RR = 1.19; 95% CI [1.08; 1.31]), while HBP showed no significant differences. Regarding the improvement of HBP, total gastrectomy was significantly superior to subtotal gastrectomy (95% CI [1.01; 2.64]). A trend towards Roux-en-Y Esophagojejunostomy as the best option for T2DM remission was observed (95% CI [0.98; 2.77]; p = 0.06). Gastrectomy with Roux-en-Y reconstruction appears to be the most effective treatment for T2DM remission. Further research is needed to assess the impact of OS on metabolic diseases.

Scientific Evidence for the Updated Guidelines on Indications for Metabolic and Bariatric Surgery (IFSO/ASMBS)

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

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.

Oncometabolic surgery in gastric cancer patients with type 2 diabetes

The rates of early gastric cancer and type 2 diabetes mellitus(T2DM) are sharply increasing in Korea. Oncometabolic surgery in which metabolic surgery is conducted along with cancer surgery is a method used to treat gastric cancer and T2DM in one-stage operation. From 2011 to 2019, a total of 48 patients underwent long-limb Roux-en-Y gastrectomy (LRYG) in Inha University Hospital, and all data were reviewed retrospectively. A 75 g oral glucose tolerance test and serum insulin level test were performed before and 1 week and 1 year after surgery. One year after LRYG operation, 25 of 48 patients showed complete or partial remission and 23 patients showed non-remission of T2DM. The preoperative HbA1c level was significantly lower and the change in HbA1c was significantly greater in the T2DM remission group. Insulin secretion indices(insulinogenic index and disposition index) were increased significantly in the T2DM remission group. In contrast, the insulin resistance indices (homeostatic model assessment of insulin resistance (HOMA-IR) and Matsuda index) changed minimal. In the case of LRYG in T2DM patients, remnant β cell function is an important predictor of favorable glycemic control.

Association between 1,5-Anhydroglucitol and Acute C Peptide Response to Arginine among Patients with Type 2 Diabetes

OBJECTIVE

The aim of this study was to explore the association of 1,5-anhydroglucitol with acute C peptide response (ACPR) to arginine among patients with type 2 diabetes.

METHODS

Patients with type 2 diabetes were enrolled from the Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital. ACPR was assessed using arginine stimulation test. Decreased β-cell function was defined as ACPR < 2.1. Multivariable logistic regression models were used to demonstrate the association between 1,5-anhydroglucitol and decreased β-cell function.

RESULTS

Finally, 623 patients with type 2 diabetes were enrolled into the analysis. Multivariable-adjusted odds ratios for decreased β-cell function across quartiles of 1,5-anhydroglucitol were 1.00, 0.47 (95% confidence interval (CI) 0.23-0.99), 0.41 (95% CI 0.20-0.84), and 0.27 (95% CI 0.13-0.57) (P _trend = 0.042), respectively. When 1,5-anhydroglucitol was considered as a continuous variable after logarithm, the corresponding odds ratio was 0.40 (95% CI 0.23-0.71).

CONCLUSIONS

We demonstrated a dose-response linear association between 1,5-anhydroglucitol and ACPR. 1,5-Anhydroglucitol was likely to be associated with β-cell function. Further analysis with large sample size and prospective study design is warranted to validate our findings.

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.

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.

Metabolic Surgery in Korea: What to Consider before Surgery

Obesity is increasing globally and represents a significant global health problem because it predisposes towards various diseases, such as type 2 diabetes mellitus, cardiovascular disease, degenerative joint disease, and certain types of cancer. Numerous studies have shown that bariatric surgery reduces body mass and ameliorates obesity-related complications, such as hypertension and hyperglycemia, suggesting that surgery is the most effective therapeutic option for severely obese and obese diabetic patients. Recent international guidelines recommend surgical treatment for diabetic patients with class III obesity (body mass index [BMI] >40 kg/m²), regardless of their level of glycemic control or the complexity of their glucose-lowering regimens, and for patients with class II obesity (BMI 35.0 to 39.9 kg/m²) and hyperglycemia that is poorly controlled despite appropriate lifestyle and pharmacological therapy. The most popular procedures are Roux-en-Y gastric bypass and sleeve gastrectomy, but new procedures with better outcomes have been reported. For optimal surgical outcome, comprehensive management including assessments of a medical condition, nutrition, mental health, and social support is needed before and after surgery. However, there is still a lack of understanding regarding metabolic surgery in Korea. Therefore, this article reviews indications for metabolic surgery in patients with a specific focus on the situation in Korea.