Role of metabolic surgery in less obese or non-obese subjects with type 2 diabetes: influence over cardiovascular events

Impact of Metabolic Surgery on Type 2 Diabetes Mellitus, Cardiovascular Risk Factors, and Mortality: A Review

BACKGROUND

The association between obesity and a reduction in life expectancy is well established, and cardiovascular disease is a leading cause of mortality. Bariatric surgery has long been established as the most effective and durable intervention for obesity, and is the only intervention for obesity that consistently improves multiple comorbidities, reduces cardiovascular disease and long-term mortality. The purpose of this review is to describe the impact of metabolic/bariatric surgery on type 2 diabetes mellitus and cardiometabolic parameters, including cardiovascular mortality.

METHODS

A systematic literature search of Pubmed, MEDLINE, and Cochrane Central Register was performed. We included randomized controlled trials, meta-analysis, case-control trials, and cohort studies that contain data on reductions in cardiovascular risk factors and cardiovascular mortality in subjects who underwent metabolic/bariatric surgery from January 1, 2005 to June 1, 2020.

CONCLUSION

There is sufficient evidence from randomized controlled trials that metabolic/bariatric surgery is associated with a significant improvement of all cardiovascular risk factors. Although studies are showing a reduction of macrovascular events and cardiovascular mortality, these findings come from observational studies and should be confirmed in randomized clinical trials.

Roux-en-Y gastric bypass for nonobese patients with uncontrolled type 2 diabetes: a long-term evaluation

BACKGROUND

There is growing evidence that the impact of Roux-en-Y gastric bypass (RYGB) on type 2 diabetes (T2D) occurs regardless of the amount of weight loss. Taking this background into consideration, it is plausible to study this procedure in individuals with lower body mass index (BMI) under clinical treatment failure for uncontrolled T2D.

OBJECTIVES

To elucidate the long-term impact of RYGB on T2D regression in a non-obese population.

SETTING

Hospital das Clínicas, Federal University of Pernambuco, Brazil.

METHODS

Twelve patients with BMI 25 to 30 kg/m² and inadequately controlled T2D underwent RYGB and were followed up for 6 years. Fasting plasma glucose, glycated hemoglobin, BMI, and the use of insulin and/or oral hypoglycemic agents were assessed. Each variable was analyzed in 3 distinct moments: preoperative evaluation, 2-year postoperative follow-up (2-PO), and 6-year postoperative follow-up (6-PO).

RESULTS

There were no cases of early or late mortality. Mean BMI at preoperative evaluation, 2-PO, and 6-PO were 28.1 ± 1.2; 23.2 ± 2.4; and 24.7 ± 3.1, respectively. The lowest BMI at 6-PO was 19.1 kg/m². Complete remission of T2D was achieved in 16.7%, partial remission in another 16.7%, glycemic control in 25%, and glycemic improvement in 25% of the sample at 6-PO; 16.7% did not present positive glycemic outcomes. Only 1 patient needed to resume insulin administration between 2-PO and 6-PO.

CONCLUSIONS

RYGB was found to be safe and effective in treating uncontrolled T2D in non-obese patients, providing improvements in the glycemic patterns in 83.4% of our sample.

The Role of Laparoscopic Mini-Gastric Bypass in Management of Metabolic Syndrome

OBJECTIVE

The study was performed to evaluate the technique of laproscopic minigastric bypass for metabolic syndrome patients.

STUDY DESIGN

The patients were enrolled in a combined prospective study and had a retrospectively gathered outcome analysis.

PATIENT AND METHODS

The study includes thirty patients; 24 females and 6 males suffering from metabolic syndrome with a mean age of 33.15 ± 10.17 years (range, 20-59), who fulfilled the criteria for bariatric surgery with BMI >35 with associated co-morbidities, all patients underwent laparoscopic mini-gastric bypass.

RESULTS

BMI and WC were significantly reduced post-operatively; also co-morbidities as DM, hypertension and dyslipidemia were resolved or controlled. The mean operative time was 90 ± 12.6 min (range, 80-120). No mortality was reported within 30 days of surgery.

CONCLUSION

Laparoscopic mini gastric bypass is an effective procedure for the treatment of obesity, HTN, type 2 DM and dyslipidemia, technically feasible, safe operation with a low rate of major postoperative complications.

Metabolic surgery: gastric bypass for the treatment of type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is one of the largest health emergencies of the 21st century given the worldwide increase of obesity during the last decades and its close association. T2DM is an inherited, polygenic and chronic disease caused by the interaction between several genetic variants in genes and the environment. The continuous search for new and more effective tools to achieve appropriate glycemic control became imperative in order to reduce long-term complications and mortality rates related to T2DM. Treatment options includes lifestyle modifications and several pharmacotherapies as first step in the therapeutical algorithm, but high corps of evidence have shown that gastrointestinal (GI) operations, especially those that involve food rerouting through the GI tract, are safe interventions and achieve superior outcomes for improvement in glucose metabolism when comparing with optimal medical and lifestyle changes. GI Surgery, specially Roux-en-Y gastric bypass (RYGB), is currently the most accepted surgical procedure to treat T2DM, and has also demonstrated to reduce significantly other cardiovascular risk factors (lipids and blood pressure control) when compared with optimal medical treatment, with good long-term effects on cardiovascular risks and mortality. Although the most effective technique in achieving diabetes remission is biliopancreatic diversion, the effectiveness-adverse effects balance is superior for RYGB. For these reasons, metabolic surgery (which was defined as "the operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain") has been considered and accepted as a new step in the therapeutic algorithm for T2DM when optimal lifestyle and medical interventions don't achieve optimal glycemic goals.

[Diabetes mellitus and cardiovascular risk: Working group recommendations of Diabetes and Cardiovascular Disease of the Spanish Society of Diabetes (SED, 2015)]

The present paper updates the Clinical Practice Recommendations for the management of cardiovascular risk factors (CVRF) in diabetes mellitus. This is a medical consensus agreed by an independent panel of experts from the Spanish Society of Diabetes (SED). Several consensuses have been proposed by scientific and medical Societies to achieve clinical goals. However, the risk score for general population may lack sensitivity for individual assessment or for particular groups at risk, such as diabetics. Traditional risk factors together with non-traditional factors are reviewed throughout this paper. Intervention strategies for managing CVRF in the diabetic patient are reviewed in detail: balanced food intake, weight reduction, physical exercise, smoking cessation, reduction in HbA1c, therapy for high blood pressure, obesity, lipid disorders, and platelet anti-aggregation. It is hoped that these guidelines can help clinicians in the decisions of their clinical activity. This regular update by the SED Cardiovascular Disease Group of the most relevant concepts, and of greater practical and realistic clinical interest, is presented in order to reduce CVR of diabetics.

How Durable Are the Effects After Metabolic Surgery?

Bariatric surgery was initially developed as a tool for weight reduction only, but it is gaining popularity because of its remarkable effect on glucose metabolism in morbidly obese and less obese patients. Recent publications have shown the superiority of metabolic surgery over medical treatment for diabetes, creating a new field of clinical research that is currently overflowing in the medical community with outstanding high-quality data. Metabolic surgery is effective in treating diabetes, even in non-morbidly obese patients.

Efficacy of Laparoscopic Mini Gastric Bypass for Obesity and Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Background. Controversies on the utility of laparoscopic mini gastric bypass (LMGB) in weight loss and type 2 diabetes mellitus (T2DM) control still exist. Methods. We conducted a comprehensive literature search of PubMed, EMBASE, and Cochrane Library. Review Manager was used to perform the meta-analysis and the weighted mean difference (WMD) and/or odds ratio with 95% confidence interval (95% CI) were used to evaluate the overall size effect. Results. The literature search identified 16 studies for systematic review and 15 articles for meta-analysis. Compared with LAGB, LSG, and LRYGB, LMGB showed significant weight loss [WMD, −6.58 (95% CI, −9.37, −3.79), P < 0.01 (LAGB); 2.86 (95% CI, 1.40, 5.83), P = 0.004 (LSG); 10.33 (95% CI, 4.30, 16.36), P < 0.01 (LRYGB)] and comparable/higher T2DM remission results [86.2% versus 55.6%, P = 0.06 (LAGB); 89.1% versus 76.3%, P = 0.004 (LAGB); 93.4% versus 77.6%, P = 0.006 (LAGB)]; LMGB also had shorter learning curve and less operation time than LRYGB [WMD, −35.2 (95% CI, −46.94, −23.46)]. Conclusions. LMGB appeared to be effective in weight loss and T2DM remission and noninferior to other bariatric surgeries. However, clinical utility of LMGB needs to be further validated by future prospective randomized controlled trials.

The BMI: Is It Time to Scratch for a More Accurate Assessment of Metabolic Dysfunction?

The body mass index (BMI = Kg/M(2)) is not a valid measure for clinical decisions, especially whether a patient will benefit from bariatric surgery. The measure, as used, discriminates against the muscular, the aged, women, and racial groups such as Asians and African Americans. The requirement must be eliminated since it denies many patients the only currently available therapy. This chapter provides the bibliographic data to support this argument and should prove useful in convincing carriers that the BMI is an inaccurate and, too often, cruel guideline.

Lipidomic profiling before and after Roux-en-Y gastric bypass in obese patients with diabetes

Bariatric surgery is a well-established approach to improve metabolic disease in morbidly obese patients with high cardiovascular risk. The post-operative normalization of lipid metabolism has a central role in the prevention of future cardiovascular events. The aim of the present study therefore was to characterize changes of plasma lipidomic patterns, consisting of 229 lipid species of 13 lipid classes, 3 months after Roux-en-Y gastric bypass (RYGB) in morbidly obese patients with and without diabetes. RYGB resulted in a 15-32% decrease of body mass index, which was associated with a significant reduction of total cholesterol (TC, -28.3%; P=0.02), LDL-cholesterol (LDL-C, -26.8%; P=0.03) and triglycerides (TGs, -63.0%; P=0.05) measured by routine clinical chemistry. HDL-cholesterol remained unchanged. The effect of RYGB on the plasma lipidomic profile was characterized by significant decreases of 87 lipid species from triacylglycerides (TAGs), cholesterol esters (CholEs), lysophosphatidylcholines (LPCs), phosphatidylcholines (PCs), phosphatidylethanolamine ethers (PEOs), phosphatidylinositols (PIs) and ceramides (Cers). The total of plasma lipid components exhibited a substantial decline of 32.6% and 66 lipid species showed a decrease by over 50%. A direct correlation with HbA1C values could be demonstrated for 24 individual lipid species (10 TAG, three CholE, two LPC, one lysophosphatidylcholine ethers (LPCO) (LPC ether), one PC, two phosphatidylcholine ethers (PCO) and five Cer). Notably, two lipid species (TAG 58:5 and PEO 40:5) were inversely correlated with HbA1C. LPCO, as single whole lipid class, was directly related to HbA1C. These data indicate that RYGB-induced modulation of lipidomic profiles provides important information about post-operative metabolic adaptations and might substantially contribute to improvements of glycemic control. These striking changes in the human plasma lipidome may explain acute, weight independent and long-term effects of RYGB on the cardiovascular system, mental status and immune regulation.