Exploring the impact of bariatric surgery on high density lipoprotein

Banded Versus Non-banded Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

Standard bariatric surgeries include biliopancreatic diversion (BPD), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and adjustable gastric banding (AGB). Laparoscopic sleeve gastrectomy (LSG) is currently favored due to safety, efficacy, and shorter operation time. However, previous literature shows 75.6% weight regain post LSG. Introducing Laparoscopic band sleeve gastrectomy (LBSG) to maintain pouch size is proposed to improve outcomes and reduce weight regain. This study aims to compare the safety and efficacy of LSG vs. LBSG in obese patients. A comprehensive search strategy was executed to identify pertinent literature comparing LBSG and LSG in obese patients. Eligible studies underwent independent screening, and pertinent data were systematically extracted. The analysis employed pooled risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous variables, each accompanied by their respective 95% confidence intervals (CI). Our systematic review and meta-analysis included 15 studies encompassing 3929 patients. Regarding body mass index (BMI), at six, 12, and 24 months, no substantial differences were found between LBSG and LSG groups (p < 0.05). Still, at 36 months, LBSG exhibited significantly lower BMI than LSG (MD = -2.07 [-3.84, -0.29], p = 0.02). Excess Weight Loss (EWL) favored LBSG at 12, 24, and 36 months with MD of 3.30 [0.42, 6.18], 4.13 [1.44, 6.81], and 18.43 [9.44, 27.42], p = 0.02, 0.003, < 0.00001, respectively). Operative time did not significantly differ between the procedures (MD = 2.95, 95%CI [-0.06, 5.95], p = 0.05). Resolution of comorbidities, overall complications, post-operative bleeding, reflux, and early complications did not significantly differ between LBSG and LSG. However, LBSG showed higher post-operative regurgitation than LSG (RR = 2.38, 95%CI [1.25, 4.54], p = 0.008). LBSG showed a substantial decrease in BMI at three-year follow-up and higher EWL at one, two, and three years. However, LBSG procedures exhibited a higher incidence of post-operative regurgitation symptoms than LSG. No substantial differences were noted in BMI at six, 12, or 24 months, EWL at six months, operative time, bleeding, reflux, or overall complications.

Treatment of obesity by acupuncture combined with medicine based on pathophysiological mechanism: A review

Obesity is a complex, multifactorial disease. The incidence of overweight and obesity has doubled worldwide since 1980, and nearly one-third of the world population is now classified as overweight or obese. Obesity rates are increasing in all age groups and for both sexes, regardless of geographic region, race, or socioeconomic status, although they are generally higher in older adults and women. Although the absolute prevalence of overweight and obesity varies widely, this trend is similar across different regions and countries. In some developed countries, the prevalence of obesity has levelled off over the past few years. However, obesity has become a health problem that cannot be ignored in low- and middle-income countries. Although the drug treatment model of modern medicine has a significant therapeutic effect in the treatment of obesity, its adverse effects are also obvious. Acupuncture combined with Chinese medicine treatment of obesity has prominent advantages in terms of clinical efficacy, and its clinical safety is higher, with fewer adverse reactions. The combination of acupuncture and medicine in the treatment of obesity is worth exploring.

Fecal Microbiota Transplantation for Weight and Glycemic Control of Obesity as Well as the Associated Metabolic Diseases: Meta-Analysis and Comprehensive Assessment

Objectives: An analysis of the weight and blood glucose management associated with fecal microbiota transplantation (FMT) as well as metabolic diseases associated with FMT was conducted by the authors in order to provide clinical recommendations regarding the treatment of nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM). Methods: We searched PubMed, Embase, and the Cochrane Library for papers that were published between the creation of the database and October 2022. We reviewed research that investigated how FMT affected weight and glycemic management in cases of obesity and metabolic conditions that are related to obesity. Studies that were published more than once, lacked the entire text, included insufficient information, or were impossible to extract data from were excluded. Additionally, case reports, reviews, and systematic reviews were excluded from the analysis. In order to analyze the data, STATA 15.1 was used. Outcomes: When we combined all of our findings, we discovered that pooled outcomes showed that weight levels (WMD equals -4.77, 95%CI: -7.40~-2.14), BMI levels (WMD equals -1.59, 95%CI: -2.21~-0.97), HOMA-IR (WMD equals -0.79, 95%CI: -1.57~-0.00), and HbA1c (WMD equals -0.65, 95%CI: -0.75~-0.55) after FMT treatment were significantly lower than before treatment. However, FMT treatment may have no effect on glucose and insulin levels in obese patients at fasting and related metabolic diseases. Additionally, subgroup analysis outcomes found that FMT significantly reduced fasting blood glucose in people with diabetes. Conclusions: As a weight loss and glycemic control therapy, FMT helps to prevent and treat metabolic problems linked to obesity, and is a viable alternative to bariatric surgery for patients who do not wish to undergo the procedure.

Crosstalk between high-density lipoproteins and endothelial cells in health and disease: Insights into sex-dependent modulation

Atherosclerotic cardiovascular disease is the leading cause of death worldwide. Intense research in vascular biology has advanced our knowledge of molecular mechanisms of its onset and progression until complications; however, several aspects of the patho-physiology of atherosclerosis remain to be further elucidated. Endothelial cell homeostasis is fundamental to prevent atherosclerosis as the appearance of endothelial cell dysfunction is considered the first pro-atherosclerotic vascular modification. Physiologically, high density lipoproteins (HDLs) exert protective actions for vessels and in particular for ECs. Indeed, HDLs promote endothelial-dependent vasorelaxation, contribute to the regulation of vascular lipid metabolism, and have immune-modulatory, anti-inflammatory and anti-oxidative properties. Sex- and gender-dependent differences are increasingly recognized as important, although not fully elucidated, factors in cardiovascular health and disease patho-physiology. In this review, we highlight the importance of sex hormones and sex-specific gene expression in the regulation of HDL and EC cross-talk and their contribution to cardiovascular disease.

Medium/long term evaluation of lipid profile after bariatric surgery (gastric bypass versus sleeve gastrectomy)

INTRODUCTION

Bariatric surgery aims to reduce weight and resolve the comorbidities associated with obesity. Few studies have assessed mid/long-term changes in lipid profile with sleeve gastrectomy versus gastric bypass. This study was conducted to assess and compare changes in lipid profile with each procedure after 60 months.

METHODS

This was an observational, retrospective study of analytical cohorts enrolling 100 patients distributed into two groups: 50 had undergone gastric bypass (GBP) surgery and 50 sleeve gastrectomy (SG) surgery. Total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglyceride (TG) levels were measured before surgery and at 1, 6, 12, 24, 36, 48, and 60 months. Weight loss and the resolution of dyslipidemia with each of the procedures were also assessed.

RESULTS

Ninety-five of the 100 patients completed follow-up. At 60 months, TC and LDL levels had significantly decreased in the BPG group (167.42 ± 31.22 mg/dl and 88.06 ± 31.37 mg/dl, respectively), while there were no differences in the SG group. Increased HDL levels were seen with both procedures (BPG: 62.69 ± 16.3 mg/dl vs. SG: 60.64 ± 18.73 mg/dl), with no difference between the procedures. TG levels decreased in both groups (BPG: 86.06 ± 56.57 mg/dl vs. SG: 111.09 ± 53.08 mg/dl), but values were higher in the BPG group (P < .05). The percentage of overweight lost (PSP) was higher in the BPG group: 75.65 ± 22.98 mg/dl vs. the GV group: 57.83 ± 27.95 mg/dl.

CONCLUSION

Gastric bypass achieved better mid/long-term results in terms of weight reduction and the resolution of hypercholesterolemia as compared to sleeve gastrectomy. While gastric bypass improved all lipid profile parameters, sleeve gastrectomy only improved HDL and triglyceride levels.

The Effects of Bariatric Surgery on Vitamin B Status and Mental Health

Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.

Medium/long term evaluation of lipid profile after bariatric surgery (gastric bypass versus sleeve gastrectomy)

INTRODUCTION

Bariatric surgery aims to reduce weight and resolve the comorbidities associated with obesity. Few studies have assessed mid/long-term changes in lipid profile with sleeve gastrectomy versus gastric bypass. This study was conducted to assess and compare changes in lipid profile with each procedure after 60 months.

METHODS

This was an observational, retrospective study of analytical cohorts enrolling 100 patients distributed into two groups: 50 had undergone gastric bypass (GBP) surgery and 50 sleeve gastrectomy (SG) surgery. Total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglyceride (TG) levels were measured before surgery and at 1, 6, 12, 24, 36, 48 and 60 months. Weight loss and the resolution of dyslipidemia with each of the procedures were also assessed.

RESULTS

Ninety-five of the 100 patients completed follow-up. At 60 months, TC and LDL levels had significantly decreased in the GBP group (167.42±31.22mg/dl and 88.06±31.37mg/dl, respectively), while there were no differences in the SG group. Increased HDL levels were seen with both procedures (GBP: 62.69±16.3mg/dl vs. SG: 60.64±18.73mg/dl), with no difference between the procedures. TG levels decreased in both groups (GBP: 86.06±56.57mg/dl vs. SG: 111.09±53.08mg/dl), but values were higher in the GBP group (p<0.05). The percentage of overweight lost (PSP) was higher in the GBP group: 75.65±22.98mg/dl vs. the GV group: 57.83±27.95mg/dl.

CONCLUSION

Gastric bypass achieved better mid/long-term results in terms of weight reduction and the resolution of hypercholesterolemia as compared to sleeve gastrectomy. While gastric bypass improved all lipid profile parameters, sleeve gastrectomy only improved HDL and triglyceride levels.

Effects of bariatric surgery on lipid-lipoprotein profile

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

Obesity: Epidemiology, Pathophysiology, and Therapeutics

Obesity is a complex multifactorial disease that accumulated excess body fat leads to negative effects on health. Obesity continues to accelerate resulting in an unprecedented epidemic that shows no significant signs of slowing down any time soon. Raised body mass index (BMI) is a risk factor for noncommunicable diseases such as diabetes, cardiovascular diseases, and musculoskeletal disorders, resulting in dramatic decrease of life quality and expectancy. The main cause of obesity is long-term energy imbalance between consumed calories and expended calories. Here, we explore the biological mechanisms of obesity with the aim of providing actionable treatment strategies to achieve a healthy body weight from nature to nurture. This review summarizes the global trends in obesity with a special focus on the pathogenesis of obesity from genetic factors to epigenetic factors, from social environmental factors to microenvironment factors. Against this background, we discuss several possible intervention strategies to minimize BMI.

High Density Lipoproteins: Metabolism, Function, and Therapeutic Potential

High Density Lipoproteins (HDLs) have long been considered as “good cholesterol,” beneficial to the whole body and, in particular, to cardio-vascular health. However, HDLs are complex particles that undergoes dynamic remodeling through interactions with various enzymes and tissues throughout their life cycle, making the complete understanding of its functions and roles more complicated than initially expected. In this review, we explore the novel understanding of HDLs' behavior in health and disease as a multifaceted class of lipoprotein, with different size subclasses, molecular composition, receptor interactions, and functionality. Further, we report on emergent HDL-based therapeutics tested in small and larger scale clinical trials and their mixed successes.

Outcomes of Bariatric Surgery Versus Medical Management for Type 2 Diabetes Mellitus: a Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Bariatric surgery improves type 2 diabetes (T2D) in obese patients. The sustainability of these effects and the long-term results have been under question.

OBJECTIVE

To compare bariatric surgery versus medical management (MM) for T2D based on a meta-analysis of randomized controlled trials (RCTs) with 2 years of follow-up.

MATERIAL AND METHODS

Seven RCTs with at least 2-year follow-up were identified. The primary endpoint was remission of T2D (full or partial). Four hundred sixty-three patients with T2D and body mass index > 25 kg/m² were evaluated.

RESULTS

After 2 years, T2D remission was observed in 138 of 263 patients (52.5%) with bariatric surgery compared to seven of 200 patients (3.5%) with MM (risk ratio (RR) = 10, 95% CI 5.5-17.9, p < 0.001). Subgroup analysis of the Roux-en-Y gastric bypass (RYGB) showed a significant effect size at 2 years in favor of RYGB over MM for a higher decrease of HbA1C (0.9 percentage points, 95% CI 0.6-1.1, p < 0.001), decrease of fasting blood glucose (35.3 mg/dl, 95% CI 13.3-57.3, p = 0.002), increase of high-density lipoprotein (HDL) (12.2 mg/dl, 95% CI 7.6-16.8, p < 0.001), and decrease of triglycerides (32.4 mg/dl, 95% CI 4.5-60.3, p = 0.02). Four studies followed patients up to 5 years and showed 62 of 225 patients (27.5%) with remission after surgery, compared to six of 156 patients (3.8%) with MM (RR = 6, 95% CI 2.7-13, p < 0.001).

CONCLUSION

This meta-analysis shows a superior and persistent effect of bariatric surgery versus MM for inducement of remission of T2D. This benefit of bariatric surgery was significant at 2 years and superior to MM even after 5 years. Compared with MM, patients with RYGB had better glycemic control and improved levels of HDL and triglycerides.

Late Relapse of Diabetes After Bariatric Surgery: Not Rare, but Not a Failure

OBJECTIVE

To characterize the status of cardiometabolic risk factors after late relapse of type 2 diabetes mellitus (T2DM) and to identify factors predicting relapse after initial diabetes remission following bariatric surgery to construct prediction models for clinical practice.

RESEARCH DESIGN AND METHODS

Outcomes of 736 patients with T2DM who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at an academic center (2004-2012) and had ≥5 years' glycemic follow-up were assessed. Of 736 patients, 425 (58%) experienced diabetes remission (HbA_1c <6.5% [48 mmol/mol] with patients off medications) in the 1st year after surgery. These 425 patients were followed for a median of 8 years (range 5-14) to characterize late relapse of diabetes.

RESULTS

In 136 (32%) patients who experienced late relapse, a statistically significant improvement in glycemic control, number of diabetes medications including insulin use, blood pressure, and lipid profile was still observed at long-term. Independent baseline predictors of late relapse were preoperative number of diabetes medications, duration of T2DM before surgery, and SG versus RYGB. Furthermore, patients who relapsed lost less weight during the 1st year after surgery and regained more weight afterward. Prediction models were constructed and externally validated.

CONCLUSIONS

While late relapse of T2DM is a real phenomenon (one-third of our cohort), it should not be considered a failure, as the trajectory of the disease and its related cardiometabolic risk factors is changed favorably after bariatric surgery. Earlier surgical intervention, RYGB (compared with SG) and more weight loss (less late weight regain) are associated with less diabetes relapse in the long-term.

The Outcome of Bariatric Surgery in Patients Aged 75 years and Older

BACKGROUND

Bariatric surgery has been shown to be safe and effective in patients aged 60-75 years; however, outcomes in patients aged 75 or older are undocumented.

METHODS

Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied.

RESULTS

A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75-81), and the median preoperative body mass index (BMI) was 41.4 kg/m² (range 35.8-57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n = 11, 58%), adjustable gastric band (AGB) (n = 4, 21%), Roux-en-Y gastric bypass (RYGB) (n = 2, 11%), banded gastric plication (n = 1, 5%), and gastric plication (n = 1, 5%). The median operative time was 120 min (range 75-240), and the median length of stay was 2 days (range 1-7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4-22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities.

CONCLUSION

Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery.

Malnutrition as a Complication of Bariatric Surgery - A Clear and Present Danger?

Obesity is a chronic life-threatening disease, and bariatric surgery is the most effective treatment in those patients. The two main operations are laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB). LSG carries a smaller risk for nutritional deficiencies, while gastric bypass procedures are associated with increased nutritional deficiencies because the procedure is more complex and changes the gastrointestinal anatomy. Recent studies comparing LSG and RYGB have proven that these types of operation may lead to a similar weight reduction effect but cause different micronutrient deficiencies. Types of malnutrition after bariatric surgery include protein-energy malnutrition and deficiencies of micronutrients, such as iron, folate, vitamin A, and vitamin B₁₂. Bariatric patients who do not adhere to the recommended diets are at a greater risk of developing relevant malnutrition. Therefore, life-long postoperative clinical and laboratory monitoring is necessary to diagnose deficiencies of vitamins, trace elements, and minerals and to correct them with supplements. Unfortunately, no standardized aftercare regimes exist for these patients, and the costs for nutritional supplements are paid by the patients themselves.

Prospective Longitudinal Trends in Body Composition and Clinical Outcomes 3 Years Following Sleeve Gastrectomy

BACKGROUND AND AIMS

Longitudinal assessment of body composition following bariatric surgery allows monitoring of health status. Our aim was to elucidate trends of anthropometric and clinical outcomes 3 years following sleeve gastrectomy (SG).

METHODS

A prospective cohort study of 60 patients who underwent SG. Anthropometrics including body composition analysis measured by multi-frequency bioelectrical impedance analysis, blood tests, liver fat content measured by abdominal ultrasound and habitual physical activity were evaluated at baseline and at 6 (M6), 12 (M12), and 36 (M36) months post-surgery.

RESULTS

Sixty patients (55% women, age 44.7 ± 8.7 years) who completed the entire follow-up were included. Fat mass (FM) was reduced significantly 1 year post-surgery (55.8 ± 11.3 to 26.7 ± 8.3 kg; P < 0.001) and then increased between 1 and 3 years post-operatively, but remained below baseline level (26.7 ± 8.3 to 33.1 ± 11.1 kg; P < 0.001). Fat free mass (FFM) decreased significantly during the first 6 months (64.7 ± 14.3 to 56.9 ± 11.8 kg; P < 0.001), slightly decreased between M6 and M12 and then reached a plateau through M36. Weight loss "failure" (< 50% excess weight loss) was noticed in 5.0% and 28.3% of patients at M12 and M36, respectively. Markers of lipid and glucose metabolism changed thereafter in parallel to the changes observed in FM, with the exception of HDL-C, which increased continuingly from M6 throughout the whole period analyzed (45.0 ± 10.2 to 59.5 ± 15.4 mg/dl; P < 0.001) and HbA1c which continued to decrease between M12 and M36 (5.5 ± 0.4 to 5.3 ± 0.4%; P < 0.001). There were marked within-person variations in trends of anthropometric and clinical parameters during the 3-year follow-up.

CONCLUSIONS

Weight regain primarily attributed to FM with no further decrease in FFM occurs between 1 and 3 years post-SG. FM increase at mid-term may underlie the recurrence of metabolic risk factors and can govern clinical interventions.

Sleeve Gastrectomy: Metabolic Surgical Procedure of Choice?

Roux-en-Y gastric bypass and sleeve gastrectomy (SG) are fairly similar in terms of their long-term effects on excess body weight, cardiometabolic risk factors, and quality of life. However, SG appears to be a safer procedure with distinct metabolic advantages, which can be even better than gastric bypass in some aspects.

Mid-term results of bariatric surgery in morbidly obese Japanese patients with slow progressive autoimmune diabetes

INTRODUCTION

Bariatric surgery is recognized as an effective treatment for type 2 diabetes mellitus, but data on its efficacy for type 1 diabetes mellitus, especially slowly progressive insulin-dependent diabetes mellitus, are limited.

METHODS

We investigated five Japanese patients with slowly progressive insulin-dependent diabetes mellitus who underwent bariatric surgery at our center.

RESULTS

Five morbidly obese glutamic acid decarboxylase antibody-positive diabetic patients underwent two different types of bariatric surgery. The mean titer of anti-glutamic acid decarboxylase antibody was 4.6 U/mL, and the mean preoperative bodyweight and BMI were 113 kg and 39.6 kg/m² , respectively. The mean hemoglobin A1c was 8.4%. The mean fasting serum C-peptide was 5.0 ng/mL. Laparoscopic sleeve gastrectomy was performed in two patients, while laparoscopic sleeve gastrectomy with duodenojejunal bypass was performed in three patients. At one year after surgery, the mean bodyweight and BMI significantly dropped, and the mean percentage of excess weight loss was 96.4%. The mean hemoglobin A1c was 5.7%. This favorable trend was maintained at mid-term.

CONCLUSION

Bariatric surgery for morbidly obese patients with anti-glutamic acid decarboxylase antibody-positive type 1 diabetes mellitus, especially slow progressive autoimmune diabetes, seemed effective in achieving mid-term glycemic control. Longer follow-up with a larger number of patients, as well as validation with more advanced patients with slowly progressive insulin-dependent diabetes mellitus, will be needed.

Laparoscopic Sleeve Gastrectomy for the Management of Type 1 Diabetes Mellitus

BACKGROUND

The prevalence of obesity is on a continuous rise worldwide, with major studies clearly correlating obesity with the development of chronic metabolic disorders including type 2 diabetes. Bariatric surgery has proven to be beneficial in the management of this condition; however, a limited number of studies exist on its effect on type 1 diabetes.

OBJECTIVE

The objective of this study is to evaluate the outcome of laparoscopic sleeve gastrectomy for the management of patients with type 1 diabetes (DM1).

SETTING

This is a retrospective cohort study conducted in a university hospital and private practice in Kuwait.

RESEARCH DESIGN AND METHODS

Analysis was conducted on 10 patients diagnosed with type 1 diabetes that underwent bariatric surgery from October 2008 until December 2016 at Amiri Hospital and Royale Hayat Hospital, Kuwait. Primary parameters included body mass index (BMI), % excess weight (%EWL) loss at follow-up, glycosylated hemoglobin (A1C), and basal insulin requirements. Total cholesterol readings and fasting blood glucose (FBS) levels were considered secondary outcomes. Statistical analysis of the data was carried out using Statistical Package for the Social Sciences (SPSS) software.

RESULTS

Mean BMI showed a reduction from 41.9 ± 5.4 to 31.4 ± 8.4 kg/m². Mean %EWL after the follow-up period was 74.4 ± 25.3%. A1C levels failed to show a significant difference 12 months post-op (p = 0.189). Cholesterol levels did not display a significant decrease either (p = 0.447). When it came to insulin requirements, a significant difference was perceived, with the mean number of units of insulin required dropping from 76.6 to 18.2 (p = 0.026). FBS readings also showed a drop from 15.1 ± 3.8 to 7.8 ± 2.9 mmol/L (p = 0.001).

CONCLUSIONS

Laparoscopic sleeve gastrectomy resulted in significant weight loss, comorbidity resolution as well as reduction in their insulin doses post-op. However, glycemic control does not seem to show significant improvement in these patients. Larger, more long-term studies are needed to reach a definite conclusion on this topic.

Neurologic Manifestations of Vitamin B Deficiency after Bariatric Surgery

INTRODUCTION

The aim of this study was to assess the incidence, clinical presentation, and outcomes of neurologic disorders secondary to vitamin B deficiencies following bariatric surgery.

METHODS

Patients at a single academic institution who underwent bariatric surgery and developed neurologic complications secondary to low levels of vitamins B1, B2, B6, and B12 between the years 2004 and 2015 were studied.

RESULTS

In total, 47 (0.7%) bariatric surgical patients (Roux-en-Y gastric bypass n = 36, sleeve gastrectomy n = 9, and duodenal switch n = 2) developed neurologic manifestations secondary to vitamin B deficiencies. Eleven (23%) patients developed postoperative anatomical complications contributed to poor oral intake. Median duration to onset of neurologic manifestation following surgery was 12 months (IQR, 5-32). Vitamin deficiencies reported in the cohort included B1 (n = 30), B2 (n = 1), B6 (n = 12), and B12 (n = 12) deficiency. The most common manifestations were paresthesia (n = 31), muscle weakness (n = 15), abnormal gait (n = 11), and polyneuropathy (n = 7). Four patients were diagnosed with Wernicke-Korsakoff syndrome (WKS) which was developed after gastric bypass (n = 3) and sleeve gastrectomy (n = 1). Seven patients required readmission for management of severe vitamin B deficiencies. Overall, resolution of neurologic symptoms with nutritional interventions and pharmacotherapy was noted in 40 patients (85%). The WKS was not reversible, and all four patients had residual mild ataxia and nystagmus at the last follow-up time.

CONCLUSIONS

Nutritional neurologic disorders secondary to vitamin B deficiency are relatively uncommon after bariatric surgery. While neurologic disorders are reversible in most patients (85%) with vitamin replacements, persistent residual neurologic symptoms are common in patients with WKS.

Circulating ANGPTL8/Betatrophin Concentrations Are Increased After Surgically Induced Weight Loss, but Not After Diet-Induced Weight Loss

BACKGROUND

ANGPTL8/betatrophin is a secreted protein reported to be involved in β-cell replication that has recently been shown to be more related to lipid metabolism. Weight loss represents a clinical situation of improvement of glucose homeostasis and overall metabolic control. The aim of the present study was to analyze the impact of weight loss induced by either a conventional dietary treatment or bariatric surgery on ANGPTL8/betatrophin concentrations.

METHODS

Serum concentrations of ANGPTL8/betatrophin were measured by ELISA in 158 subjects before and 1 year after weight loss induced either by conventional dietary treatment (n = 38) or bariatric surgery (sleeve gastrectomy, n = 20, or Roux-en-Y gastric bypass, n = 100).

RESULTS

Massive surgery-induced weight loss after SG or RYGB was accompanied by a statistically significant increase in circulating levels of ANGPTL8/betatrophin (28.1 ± 13.9 to 40.3 ± 22.8 ng/mL, P = 0.001 after SG; 24.6 ± 10.9 to 41.7 ± 19.4 ng/mL, P < 0.001 after RYGB), while remaining unchanged 25.6 ± 13.3 to 25.4 ± 10.7 ng/mL (P = 0.891) after diet-induced weight loss. The change in ANGPTL8/betatrophin levels was positively correlated with the change in HDL-C concentrations.

CONCLUSIONS

Our study showed that serum ANGPTL8/betatrophin concentrations were increased in obese subjects after surgically induced weight loss, but not after weight loss achieved by conventional dietary treatment. The change in ANGPTL8/betatrophin concentrations emerged as a significant predictor of the change in HDL-C levels after weight loss.

Biliopancreatic Diversion Decreases Postprandial Apolipoprotein A-IV Levels in Mildly Obese Individuals with Type 2 Diabetes Mellitus: a Prospective Study

BACKGROUND

Bariatric surgery usually leads to improvement on the general lipid profile, but its role in the levels of apolipoprotein A-IV (Apo-AIV) is not completely understood. Apo-AIV is a gut-released lipoprotein which is enrolled in satiety regulation and presents anti-inflammatory, anti-atherogenic, and anti-oxidative properties. The objective of this study was to determine the influence of biliopancreatic diversion (BPD) in the levels of Apo-AIV.

METHODS

This is a prospective exploratory study which evaluated eight obese individuals with type 2 diabetes mellitus (T2DM) who underwent BPD (Scopinaro operation) and were followed-up for 12 months. Apo-AIV levels were determined by means of serial dosages through a standard meal tolerance test (MTT) in the immediate preoperative period and then 12 months later.

RESULTS

There was a significant change in the Apo-AIV curve following MTT before and after surgery. At 0 and 45 min, the Apo-AIV levels did not significantly differ before and after surgery; at 120 and 180 min, Apo-AIV levels were significantly lower following BPD.

CONCLUSIONS

We observed a decrease of postprandial levels of Apo-AIV following MTT in mildly obese individuals with T2DM. This finding appears to be related to the suppression in the Apo-AIV response that obese individuals tend to present. Weight reduction itself, endotoxemia, and the large segments of bypassed intestine may be enrolled in this impaired response.

Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes

OBJECTIVE

The aim of the study was to assess long-term metabolic effects of laparoscopic sleeve gastrectomy (LSG) in patients with type 2 diabetes (T2DM) and to identify predictive factors for long-term diabetes remission and relapse.

BACKGROUND

LSG has become the most common bariatric operation worldwide. Its long-term metabolic effects in patients with T2DM are, however, unknown.

METHODS

Outcomes of 134 patients with obesity with T2DM who underwent LSG at an academic center during 2005 to 2010 and had at least 5 years of follow-up were assessed.

RESULTS

At a median postsurgical follow-up of 6 years (range: 5-9), a mean body mass index loss of -7.8 ± 5.1 kg/m (total weight loss: 16.8% ± 9.7%) was associated with a reduction in mean glycated hemoglobin (HbA1c, -1.3 ± 1.8%, P < 0.001), fasting blood glucose (-37.8 ± 70.4 mg/dL, P < 0.001) and median number of diabetes medications (-1, P < 0.001). Long-term glycemic control (HbA1c <7%) was seen in 63% of patients (vs 31% at baseline, P < 0.001), diabetes remission (HbA1c <6.5% off medications) in 26%, complete remission (HbA1c <6% off medications) in 11%, and "cure" (continuous complete remission for ≥5 years) was achieved in 3%. Long-term relapse of T2DM after initial remission occurred in 44%. Among patients with relapse, 67% maintained glycemic control (HbA1c <7%). On adjusted analysis, taking 2 or more diabetes medications at baseline predicted less long-term remission (odds ratio 0.19, 95% confidence interval 0.07-0.55, P = 0.002) and more relapse of T2DM (odds ratio 8.50, 95% confidence interval: 1.40-49.20, P = 0.02). Significant improvement in triglycerides (-53.7 ± 116.4 mg/dL, P < 0.001), high-density lipoprotein (8.2 ± 12.9 mg/dL, P < 0.001), systolic (-8.9 ± 18.7 mmHg, P < 0.001) and diastolic blood pressure (-2.6 ± 14.5 mmHg, P = 0.04), and cardiovascular risk (13% relative reduction, P < 0.001) was observed.

CONCLUSIONS

LSG can significantly improve cardiometabolic risk factors including glycemic status in T2DM. Long-term complete remission and "cure" of T2DM, however, occur infrequently.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic mini gastric bypass in the treatment of obesity: study protocol for a randomized controlled trial

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard in bariatric surgery, achieving durable long-term weight loss with improvement of obesity-related comorbidities. Lately, the laparoscopic mini gastric bypass (LMGB) has gained worldwide popularity with similar results to LRYGB in terms of weight loss and comorbidity resolution. However, there is a lack of randomized controlled trials (RCT) comparing LMGB and LRYGB. This article describes the design and protocol of a randomized controlled trial comparing the outcomes of these two bariatric procedures.

Methods/Design

The trial is designed as a single center, randomized, patient and observer blinded trial. The relevant ethics committee has approved the trial protocol. To demonstrate that LMGB is not inferior to LRYGB in terms of excess weight loss (EWL) the study is conducted as a non-inferiority trial with the sample-size calculations performed accordingly. EWL 12 months after surgery is the primary endpoint, whereas 3-year EWL, morbidity, mortality, remission of obesity related comorbidities, quality of life (QOL) and hormonal and lipid profile changes are secondary endpoints. Eighty patients, 18 years or older and with a body mass index (BMI) between 35 and 50 kg/m² who meet the Swiss guidelines for the surgical treatment of morbid obesity will be randomized. The endpoints and baseline measurements will be assessed pre-surgery, peri-surgery and post-surgery (fixed follow up measurements are at discharge and at the time points 6 weeks and 12 and 36 months postoperatively).

Discussion

With its 3-year follow up time, this RCT will provide important data on the impact of LMGB and LRYGB on EWL, remission of comorbidities, QOL and hormonal and lipid profile changes.

Trial registration

ClinicalTrials.gov, NCT02601092. Registered on 28 September 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1957-9) contains supplementary material, which is available to authorized users.

Bariatric surgery may reduce the risk of Alzheimer's diseases through GLP-1 mediated neuroprotective effects

Obesity and diabetes are associated with deficits in multiple neurocognitive domains and increased risk for dementia. Over the last two decades, there has been a significant increase in bariatric and metabolic surgery worldwide, driven by rising intertwined pandemics of obesity and diabetes, along with improvement in surgical techniques. Patients undergoing bariatric surgery achieve a significant decrease in their excess weight and a multitude of sequela associated with obesity, diabetes, and metabolic syndrome. Glucagon-like peptide 1 (GLP-1) is an intestinal peptide that has been implicated as one of the weight loss-independent mechanisms in how bariatric surgery affects type 2 diabetes. GLP-1 improves insulin secretion, inhibits apoptosis and induce pancreatic islet neogenesis, promotes satiety, and can regulate heart rate and blood pressure. Moreover, numerous studies have demonstrated potential neuroprotective and neurotrophic effects of GLP-1. Increased GLP-1 activity has been shown to increase cortical activity, promote neuronal growth, and inhibit neuronal degeneration. Specifically, in experimental studies on Alzheimer's disease, GLP-1 decreases amyloid deposition and neurofibrillary tangles. Furthermore, recent studies have also suggested that GLP-1 based therapies, new class of antidiabetic drugs, have favorable effects on neurodegenerative disorders such as Alzheimer's disease. We present a hypothesis that bariatric surgery can help delay or even prevent the onset of Alzheimer's disease in long-term by increasing the levels of GLP-1. This hypothesis has a potential for many studies from basic science projects to large population studies to fully understand the neurological and cognitive consequences of bariatric surgery and associated rise in GLP-1.

Roux-en-Y Gastric Bypass

Background:

Roux-en-Y gastric bypass (RYGB) is considered the gold standard for gastric bypass, displaying better results for metabolic disorders than other surgical procedures over the long term. The aim of this study was to determine the effects of bariatric surgery, in particular the RYGB technique, on metabolic syndrome (MS) and other biochemical parameters implicit in the comorbid conditions associated with obesity, as well as to explore the influence of this surgical procedure on psychiatric comorbidity in the study population.

Method:

An observational retrospective cohort study based on 146 clinical records of patients having undergone RYGB between January 1, 2011, and January 1, 2014, was performed. Data related to metabolic and psychiatric comorbidity were gathered at three stages: prior to surgery and at 3 and 9 months following surgery.

Results:

There was a progressive and statistically significant reduction of all biochemical parameters analyzed at 3 and 9 months following surgery except high-density lipoprotein cholesterol, which significantly increased (beneficial) in value. These changes imply a remission of >90% for all metabolic disorders and the consequent tendency toward a reduction in prescribed pharmacological treatments, with MS found in only one subject at 9 months. There was, however, no significant reduction in pharmacological treatments for psychiatric comorbidities.

Conclusion:

Findings suggest that RYGB is an effective treatment for MS and other metabolic disorders but not for psychiatric comorbidities accompanying MS.

Circulating Apolipoprotein A-IV presurgical levels are associated with improvement in insulin sensitivity after Roux-en-Y gastric bypass surgery

BACKGROUND

Apolipoprotein A-IV (ApoA-IV) has been shown to be involved in obesity and diabetes pathogenesis in animal studies, but its role in humans is uncertain.

OBJECTIVES

The objective of this study was to determine the relation of ApoA-IV with changes in glucose metabolism and weight after bariatric surgery.

SETTING

University Hospital.

METHODS

The patients (n = 49) included lean controls (n = 8) and patients before and after a mean of 7 months after laparoscopic adjustable gastric banding (LAGB, n = 12), laparoscopic Roux-en-Y gastric bypass (RYGB, n = 22), or laparoscopic sleeve gastrectomy (SG, n = 11). ApoA-IV and other hormone assays were performed in the fasting and the postprandial state. Pearson's correlation analyses controlled for baseline BMI and percent excess weight loss (EWL) were used to determine relationships between ApoA-IV levels and insulin resistance (HOMA-IR).

RESULTS

With all bariatric procedures combined, the change in ApoA-IV [533 versus 518 microg/L, P = .813] or ApoA-IV area under the curve (AUC - 1072 versus 1042, P = .939) was not significant. None of the surgeries individually affected levels of fasting or ApoA-IV AUC. Bariatric surgery resulted in a decrease in HOMA-IR (5.3 versus 2.0, P<.001). In the RYGB group, higher baseline ApoA-IV levels correlated with decrease in HOMA-IR [r = -.6, P = .008]. This relationship was independent of EWL and was not observed in the LAGB or SG group. There was no association of ApoA-IV levels with EWL, insulin secretion, Peptide-YY, or leptin levels.

CONCLUSION

Preoperative ApoA-IV levels, rather than changes in levels, positively correlate with improvements in insulin sensitivity independent of weight loss after RYGB.

Short-Term Hypocaloric High-Fiber and High-Protein Diet Improves Hepatic Steatosis Assessed by Controlled Attenuation Parameter

OBJECTIVES

Non-alcoholic fatty liver disease is one of the most prevalent liver diseases and increases the risk of fibrosis and cirrhosis. Current standard treatment focuses on lifestyle interventions. The primary aim of this study was to assess the effects of a short-term low-calorie diet on hepatic steatosis, using the controlled attenuation parameter (CAP) as quantitative tool.

METHODS

In this prospective observational study, 60 patients with hepatic steatosis were monitored during a hypocaloric high-fiber, high-protein diet containing 1,000 kcal/day. At baseline and after 14 days, we measured hepatic fat contents using CAP during transient elastography, body composition with bioelectrical impedance analysis, and serum liver function tests and lipid profiles using standard clinical-chemical assays.

RESULTS

The median age was 56 years (25-78 years); 51.7% were women and median body mass index was 31.9 kg/m(2) (22.4-44.8 kg/m(2)). After 14 days, a significant CAP reduction (14.0%; P<0.001) was observed from 295 dB/m (216-400 dB/m) to 266 dB/m (100-353 dB/m). In parallel, body weight decreased by 4.6% (P<0.001), of which 61.9% was body fat. In addition, liver stiffness (P=0.002), γ-GT activities, and serum lipid concentrations decreased (all P<0.001).

CONCLUSIONS

This study shows for the first time that non-invasive elastography can be used to monitor rapid effects of dietary treatment for hepatic steatosis. CAP improvements occur after only 14 days on short-term low-calorie diet, together with reductions of body composition parameters, serum lipids, and liver enzymes, pointing to the dynamics of hepatic lipid turnover.

Bariatric Surgery in Obese Patients With Type 1 Diabetes

OBJECTIVE

There is a paucity of data on the impact of bariatric surgery in type 1 diabetes (T1D). The aim of this review was to quantify the overall effects of bariatric surgery in obese patients with T1D.

METHODS

We searched PubMed, Scopus, ISI Web of Knowledge, and Google Scholar from their inception to December 2015 to identify all relevant studies of bariatric surgery in adult obese patients with T1D.

RESULTS

The review included 17 studies with 107 individuals, including 10 case series and 7 case reports. Overall, the dominant procedure was gastric bypass (n = 70; 65%). All studies reported a significant reduction in excess weight. A significant reduction in weight-adjusted daily insulin requirements was shown in all case series except one. Pooled mean ± SD of pre- and postoperative glycated hemoglobin (HbA1c) for the entire cohort with available data (n = 96) was 8.4 ± 1.3% and 7.9 ± 1.1%, respectively (P = 0.01). In addition to common postoperative complications, profound glycemic changes (diabetic ketoacidosis and hypoglycemia) and gastrointestinal dysmotility symptoms (prolonged ileus and acute gastric remnant dilation) have been reported. No surgical mortality was reported.

CONCLUSIONS

Bariatric surgery leads to significant weight loss in severely obese patients with T1D and results in a significant improvement in insulin requirements and glycemic status. The favorable metabolic effects of bariatric surgery may facilitate medical management of and cardiovascular risk reduction in T1D in the setting of severe obesity. Diabetic ketoacidosis and hypoglycemia are potentially serious complications. Short-term results of bariatric surgery in patients with T1D are encouraging, but larger and longer-term studies are needed.

Failed Surgical Weight Loss Does Not Necessarily Mean Failed Metabolic Effects

The metabolic profile of patients after a failed surgical weight loss procedure is unknown. Long-term clinical outcomes of 31 obese diabetes patients with post-bariatric surgery excess weight loss of ≤25% were assessed. At a median follow-up of 6 years (range, 5-9 years) after surgery, remission and clinical improvement of diabetes occurred in seven (23%) and 13 (42%) patients, respectively. A long-term mean total weight loss of 7.0±4.7% and excess weight loss of 13.7±8.5% were associated with a mean reduction in fasting blood glucose level, from 158.9±66.7 to 128.4±35.3 mg/dL (P=0.03), and a significant decrease in diabetes medication requirements (P<0.001). A significant decrease in systolic blood pressure (11.1±23.4 mm Hg, P=0.01) and level of circulating triglycerides (35.7±73.4 mg/dL, P=0.04) was also observed after surgery. A modest surgical weight loss in the range of 5-10% of initial weight was associated with significant improvement in cardiometabolic risk factors of morbidly obese diabetes patients. The markedly improved glycemic control (65% remission or clinical improvement) may be partly explained by weight-independent antidiabetes mechanisms of certain bariatric surgical procedures.

Bariatric surgery, lipoprotein metabolism and cardiovascular risk

PURPOSE OF REVIEW

To summarize recent epidemiological, preclinical and clinical studies on the effects of Roux-en-Y-gastric bypass (RYGBP) surgery on cardiovascular risk factors and the underlying mechanisms.

RECENT FINDINGS

Although RYGBP has mechanical effects on the gastrointestinal tract, the reduced gastric pouch and intestinal calorie absorption cannot fully explain the metabolic improvements.

SUMMARY

Obesity predisposes to cardiovascular risk factors such as dyslipidemia, type 2 diabetes, nonalcoholic fatty liver disease and hypertension. In contrast to the limited success of pharmacological and lifestyle interventions, RYGBP induces sustained weight loss, metabolic improvements and decreases morbidity/mortality. In line, RYGBP reduces cardiovascular risk factors. Although the mechanisms are not entirely understood, RYGBP induces complex changes in the gut affecting other organs through endocrine and metabolic signals from the intestine to all key metabolic organs, which can link RYGBP and decreased cardiovascular risk. Here, we discuss the roles of changes in lipid absorption and metabolism, bile acid metabolism, gut hormones and the microbiote as potential mechanisms in the decreased cardiovascular risk and metabolic improvement after RYGBP.