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

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.

Cholecystectomy Concomitant with Bariatric Surgery: Safety and Metabolic Effects

BACKGROUND

Obesity and fast weight loss in the postoperative period of bariatric surgery increase significantly the risk of cholelithiasis. Moreover, emerging evidence has pointed out the role of bile acids as possible metabolism and weight loss enhancers. This study aims to analyze the influence of cholecystectomy (CL) concomitant with bariatric surgery on weight loss, metabolic repercussions, and postoperative morbidity.

STUDY DESIGN

Retrospective cohort study. A total of 363 medical records were analyzed between 2002 and 2017, with 255 patients divided into four groups: with concomitant CL: sleeve gastrectomy (SG + CL group) and Roux-en-Y gastric bypass (GB + CL group); without concomitant CL: sleeve gastrectomy (SG group) and RYGB (GB group).

RESULTS

CL concomitant with bariatric surgery is not related to worse long-term metabolic outcomes when compared to isolated bariatric surgery. In the postoperative follow-up of the isolated bariatric surgeries, 18 (16.5%) patients underwent cholecystectomy. There was no statistical difference between the groups regarding post-surgical complications.

CONCLUSION

CL did not lead to worse metabolic outcomes and was also not related to a higher incidence of postoperative complications. Cholelithiasis and cholecystitis are important concerns in the postoperative period of bariatric surgery and a careful evaluation of the concomitant procedure should be performed.

The Phantom Satiation Hypothesis of Bariatric Surgery

The excitation of vagal mechanoreceptors located in the stomach wall directly contributes to satiation. Thus, a loss of gastric innervation would normally be expected to result in abrogated satiation, hyperphagia, and unwanted weight gain. While Roux-en-Y-gastric bypass (RYGB) inevitably results in gastric denervation, paradoxically, bypassed subjects continue to experience satiation. Inspired by the literature in neurology on phantom limbs, I propose a new hypothesis in which damage to the stomach innervation during RYGB, including its vagal supply, leads to large-scale maladaptive changes in viscerosensory nerves and connected brain circuits. As a result, satiation may continue to arise, sometimes at exaggerated levels, even in subjects with a denervated or truncated stomach. The same maladaptive changes may also contribute to dysautonomia, unexplained pain, and new emotional responses to eating. I further revisit the metabolic benefits of bariatric surgery, with an emphasis on RYGB, in the light of this phantom satiation hypothesis.

Metabonomic model for the assessment of type 2 diabetes remission after bariatric/metabolic surgery

OBJETIVO

To evaluate the differences in the metabonomic profile of patients who achieved remisison of Type 2 diabetes mellitus (T2DM) after bariatric surgery in relation to those who presented maintenance or recurrence of this condition after surgery.

METHODS

Thirthy-three patients with obesity and T2D were submitted to bariatric/metabolic surgery, among which, 22 experienced complete remission of T2D, and 11 did not experience remission in the postoperative period. Blood samples were taken in order to assess the serum profiles through a 1H NMR-based metabonomic study.

RESULTS

The metabonomic model for the assessment of T2D recurrence presented an accuracy of 93.9%, sensibility of 81.8%, specificity of 100%, positive predictive value of 100% and a negative predictive value of 91.7%.

CONCLUSION

bariatric surgery provide specific effects on the distribution of metabolites in those patients who achieved remission of T2DM, and this new distribution can be assessed through a metabonomic model.