Bariatric surgery in patients with type 2 diabetes: benefits, risks, indications and perspectives

Reversal and Remission of T2DM - An Update for Practitioners

Over the past 50 years, many countries around the world have faced an unchecked pandemic of obesity and type 2 diabetes (T2DM). As best practice treatment of T2DM has done very little to check its growth, the pandemic of diabesity now threatens to make health-care systems economically more difficult for governments and individuals to manage within their budgets. The conventional view has been that T2DM is irreversible and progressive. However, in 2016, the World Health Organization (WHO) global report on diabetes added for the first time a section on diabetes reversal and acknowledged that it could be achieved through a number of therapeutic approaches. Many studies indicate that diabetes reversal, and possibly even long-term remission, is achievable, belying the conventional view. However, T2DM reversal is not yet a standardized area of practice and some questions remain about long-term outcomes. Diabetes reversal through diet is not articulated or discussed as a first-line target (or even goal) of treatment by any internationally recognized guidelines, which are mostly silent on the topic beyond encouraging lifestyle interventions in general. This review paper examines all the sustainable, practical, and scalable approaches to T2DM reversal, highlighting the evidence base, and serves as an interim update for practitioners looking to fill the practical knowledge gap on this topic in conventional diabetes guidelines.

Perioperative Outcomes of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Patients with Diabetes Mellitus: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database

Background

The safety and efficacy of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) to treat obesity and associated comorbidities, including diabetes mellitus, is well established. As diabetes may add risk to the perioperative period, we sought to characterize perioperative outcomes of these surgical procedures in diabetic patients.

Methods

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we identified patients who underwent LSG and LRYGB between 2015 and 2017, grouping by non-diabetics (NDM), non-insulin-dependent diabetics (NIDDM), and insulin-dependent diabetics (IDDM). Primary outcomes included serious adverse events, 30-day readmission, 30-day reoperation, and 30-day mortality. Univariate and multivariable analyses were used to evaluate the outcome in each diabetic cohort.

Results

Multivariable analysis of patients who underwent LSG (with NDM patients as reference) showed higher 30-day mortality (NIDDM AOR = 1.52, p = 0.043; IDDM AOR = 1.91, p = 0.007) and risk of serious adverse events (NIDDM AOR = 1.15, p < 0.001; IDDM AOR = 1.58, p < 0.001) in the diabetic versus NDM groups. Multivariable analysis of patients who underwent LRYGB (with NDM patients as reference) showed higher risk of serious adverse events (NIDDM AOR = 1.09, p = 0.014; IDDM AOR = 1.43, p < 0.001) in the diabetic versus NDM groups.

Conclusions

Diabetics who underwent LSG and LRYGB had higher rates of several perioperative complications compared with non-diabetics. IDDM had a stronger association with several perioperative complications compared with NIDDM. This increase in morbidity and mortality is modest and should be weighed against the real benefits of bariatric surgery in patient with obesity and diabetes mellitus.

Pharmacological management of type 2 diabetes: what's new in 2017?

INTRODUCTION

Novelties in the management of type 2 diabetes are dominated by the commercialisation of new glucose-lowering agents, which offer alternatives to older antidiabetic medications, and by the publication of several prospective placebo-controlled outcome trials, which demonstrated not only cardiovascular safety but also cardiovascular and renal protection with some new medications. Areas covered: Updates regarding the use of glucose-lowering agents are discussed from a clinical point of view. Some new viewpoints concern older antidiabetic agents such as metformin, sulfonylureas and glitazones whose benefit-risk balance has been revisited, especially in high risk patients. The recent data regarding DPP-4 inhibitors (gliptins) focused on the safety profile of this pharmacological class, including in patients with impaired renal function. The highlight concerns the cardiovascular (and renal) protection by some GLP-1 receptor agonists (liraglutide, semaglutide) and SGLT2 inhibitors (empagliflozin, canagliflozin) in patients with high cardiovascular risk. Finally, efficacy and safety of new combinations and advances in insulin therapy will be briefly discussed. Expert commentary: The recent data from randomized controlled trials, meta-analyses and observational real-life studies should trigger a revision of the algorithm for the treatment of hyperglycemia in type 2 diabetes, especially in patients with high cardiovascular and/or renal risk.

Pharmacotherapy of 'treatment resistant' type 2 diabetes

INTRODUCTION

Despite type 2 diabetes (T2D) management offers a variety of pharmacological interventions targeting different defects, numerous patients remain with persistent hyperglycaemia responsible for severe complications. Unlike resistant hypertension, treatment resistant T2D is not a classical concept although it is a rather common observation in clinical practice. Areas covered: This article proposes a definition for 'treatment resistant diabetes', analyses the causes of poor glucose control despite standard therapy, briefly considers the alternative approaches to glucose-lowering pharmacotherapy and finally describes how to overcome poor glycaemic control, using innovative oral or injectable combination therapies. Expert opinion: Before considering intensifying the pharmacotherapy of a patient with poorly controlled T2D, it is important to verify treatment adherence, target obesity and consider various non pharmacological improvement quality interventions. If treatment resistant diabetes is defined as not achieving glycated haemoglobin target despite oral triple therapy with a third glucose-lowering agent added to metformin-sulfonylurea dual treatment, the combination of a dipeptidyl peptidase-4 (DPP-4) inhibitor and a sodium glucose cotransporter type 2 (SGLT2) inhibitor may offer new opportunities before considering injectable therapies. Insulin basal therapy (± metformin) may be optimized by the addition of a SGLT2 inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist.

Fatty Acid Composition of Adipose Tissue Triglycerides in Obese Diabetic Women After Bariatric Surgery: a 2-Year Follow up

Bariatric surgery is the most effective method in the treatment of obesity and type 2 diabetes (T2DM). The aim of this study was to evaluate the effects of different types of bariatric procedures on remission of T2DM and on the fatty acid composition in subcutaneous adipose tissue. Patients included obese diabetic women who underwent bariatric surgery: biliopancreatic diversion (BPD), n=8, laparoscopic gastric banding (LAGB), n=9 or laparoscopic greater curvature plication (LGCP), n=12. Anthropometric characteristics and fatty acid composition of adipose tissue (FA AT) were analyzed before surgery, then 6 months and 2 years after surgery. FA AT was analyzed by gas chromatography. Diabetes remission was estimated. BPD was most efficient in inducing a remission of diabetes (p=0.004). Significantly higher increases in lauric (12:0), myristoleic (14:1n-5) and palmitoleic (16:1n-7) acids and delta-9 desaturase were found two years after BPD, suggesting higher lipogenesis in adipose tissue. Docosatetraenoic acid (22:4n-6) increased significantly after BPD, while docosapentaenoic acid (22:5n-3) decreased 6 months after BPD and increased after 2 years. No changes were found after LAGB and LGCP after 2 years. Bariatric surgery led to significant changes in the fatty acid composition of subcutaneous adipose tissue in severely obese diabetic women after six months and two years, and was partly influenced by the type of surgery used.

Australian Nurse Practitioner Practice: Value Adding through Clinical Reflexivity

The role of the Australian Nurse Practitioner (NP) is in its infancy and at a crossroads where extensive research demonstrates effective quality care and yet the role remains underrecognised and underutilised. The translation of practice into “value” is critical for the sustainability of NP roles and requires the practitioner to adopt a systematic method of inquiry. Kim's (1999) “Critical Reflective Inquiry” (CRI) method was adapted by two Australian NPs who specialise in diabetes and chronic disease management. Kim highlights the intent of CRI as understanding the meaning of practice, delivering improvements to practice through self-reflection, and the critique of practice that can lead to practice changes and development of new models of care translated to “products” of value. Based on the thematically analysis of 3 years of CRI application, the authors formed 5 headings that represented the NP's practice as Specialised Care Access, Complications and Diagnostics Interventions, Pharmaceutical Treatment, Vulnerable Populations, and Leadership. The utility of CRI demonstrates how NP practice is integral to a continuous cycle of addressing health care services gaps, and the conversion of “products” into “value” and positions the NP to assimilate the role of the practitioner-researcher.

Relationship between gut hormones and glucose homeostasis after bariatric surgery

Type 2 diabetes mellitus (T2D) is emerging as a worldwide public health problem, and is mainly associated with an increased incidence of obesity. Bariatric surgery is currently considered the most effective treatment for severely obese patients. After bariatric surgery, T2D patients have shown a significant improvement in glycemic control, even before substantial weight loss and often discontinuation of medication for diabetes control. A central role for enteroendocrine cells from the epithelium of the gastrointestinal tract has been speculated in this postoperative phenomenon. These cells produce and secrete polypeptides - gut hormones - that are associated with regulating energy intake and glucose homeostasis through modulation of peripheral target organs, including the endocrine pancreas. This article reviews and discusses the biological actions of the gut hormones ghrelin, cholecystokinin, incretins, enteroglucagon, and Peptide YY, all of which were recently identified as potential candidates for mediators of glycemic control after bariatric surgery. In conclusion, current data reinforce the hypothesis that T2D reversion after bariatric surgery may be related to glycemic homeostasis developed by the intestine.

Incretin hormones and the satiation signal

Recent research has indicated that appetite-regulating hormones from the gut may have therapeutic potential. The incretin hormone, glucagon-like peptide-1 (GLP-1), appears to be involved in both peripheral and central pathways mediating satiation. Several studies have also indicated that GLP-1 levels and responses to meals may be altered in obese subjects. Clinical trial results have shown further that two GLP-1 receptor agonists (GLP-1 RAs), exenatide and liraglutide, which are approved for the treatment of hyperglycemia in patients with type 2 diabetes, also produce weight loss in overweight subjects without diabetes. Thus, GLP-1 RAs may provide a new option for pharmacological treatment of obesity.

Acute improvement in insulin resistance after laparoscopic Roux-en-Y gastric bypass: is 3 days enough to correct insulin metabolism?

BACKGROUND

Although medium- to long-term improvement in insulin resistance and T2DM after Roux-en-Y gastric bypass (RYGB) is well documented, few studies have analyzed the acute effects after surgery. Understanding these effects might help explain the physiologic adjustments after surgery and help in managing insulin resistance and controlling the hypoglycemic treatment for bariatric patients.

METHODS

We recruited a prospective cohort of 55 consecutive female patients that underwent primary laparoscopic RYGB between January and June/2011. Blood samples were collected preoperatively and at the first, third, and fifth post-operative days after an overnight fast.

RESULTS

There was a significant increase in homeostasis model assessment for insulin resistance (HOMA-IR) on day 1 (2.36 vs 3.12; p = 0.032), followed by a rapid decrease from day 3 onward (3.12 vs 1.70; <0.001). We found a statistically significant difference (p < 0.05) at all time points compared with baseline. HOMA-IR levels at POD5 were 47 % lower than baseline values and were not significantly different from values at 6 months (1.24 vs 0.93; p = 0.09). The blood levels of glucose and insulin closely matched those of HOMA-IR.

CONCLUSIONS

RYGB results in a rapid improvement in insulin resistance and a clinically significant decrease in fasting glucose and insulin levels. This improvement is significant at the 3rd post-operative day, and by the 5th day, patients express insulin resistance levels that are similar to those expressed at 6 months after surgery. This work highlights the acute metabolic impact of surgery. Understanding the behavior of insulin and glucose after surgery might improve our knowledge of the pathophysiology of diabetes and lead to novel therapies and tailored surgical approaches.

Trends in utilization and outcomes of bariatric surgery in obese people with and without type 2 diabetes in Spain (2001-2010)

AIM

Bariatric surgery is associated with a significant improvement in glucose control and even diabetes remission. There are no studies investigating national trends in the use of bariatric surgery in people with type 2 diabetes. We examine trends in the use of bariatric surgery in patients with and without type 2 diabetes between 2001 and 2010 in Spain.

METHODS

We identified patients who underwent bariatric surgery using national hospital discharge data. Discharges were grouped by diabetes status. Incidence of discharges due to bariatric surgery were calculated and stratified by diabetes status, procedure and year. We calculated length of stay (LOS) and in-hospital mortality (IHM).

RESULTS

From 2001 to 2010 13,038 bariatric surgery procedures were performed. Over the study period 23.6% (n=3080) of all patients undergoing bariatric procedure had DM as a co-diagnosis. This prevalence increased from 17.3% in 2001 to 25.5% in 2010. LOS and IHM were similar among patients with and without type 2 diabetes.

CONCLUSION

The proportion of subjects with type 2 diabetes among bariatric surgery patient has increased over time, in part due to an increase in the use of laparoscopic techniques.

Type 2 diabetes mellitus: a possible surgically reversible intestinal dysfunction

Type 2 diabetes mellitus (T2DM) is a global public health problem often associated with obesity. Bariatric surgery is effective for treating serious obesity, and techniques involving intestinal bypass have metabolic benefits, such as complete and early remission of T2DM. We present a literature review of the possible mechanisms of early normalization of glycemic homeostasis after bariatric surgery, including intestinal gluconeogenesis, increased antidiabetogenic signals from L cells located in the distal small intestine, and impaired secretion of diabetogenic signals in the upper part of the small intestine. Adding to these potential mechanisms, unknown factors that regulate insulin sensitivity may be involved and altered by bariatric surgery. This review discusses the various hypotheses about the mechanisms of glycemic control after bariatric surgery involving intestinal bypass. Further research is essential to better understand these mechanisms and to identify potential new mechanisms that might help in developing less invasive and safer alternatives for the treatment of T2DM and reveal novel pharmaceutical targets for glycemic control.

Treatment of type 2 diabetes mellitus by laparoscopic gastric bypass: an analysis of 26 cases

AIM: To summarize the initial experience with laparoscopic Roux-en-Y gastric bypass (LRYGB) in the management of patients with type 2 diabetes mellitus (T2DM).

METHODS: The clinical data for 26 T2DM patients (BMI ≥24 kg/m², HbAlc ≥7%, peptide C ≥1 μg/L) who received laparoscopic gastric bypass from May 2010 to November 2010 were retrospective1y analyzed. The changes in FBG, HbAlc, insulin and peptide C levels and in doses of hypoglycemic agents at different postoperative time points (1, 3 and 6 mo) were analyzed.

RESULTS: The operation was successful in all cases. Postoperatively, one case developed anastomotic bleeding and 2 cases developed gastroparesis, but they were all cured after conservative medical management. All cases have been followed up and the total effective rate of the operation was 96.3%. Eleven cases were free of dependence on hypoglycemic agents from weeks 3 to 8 after LRYGB, and the 3- and 6-month cure rates were 36.7% and 50%, respectively.

CONCLUSION: LRYGP is safe, feasible and effective in the management of T2DM in the short term, and long-term efficacy still need further clinical follow-up.

Risk of complications after bariatric surgery among individuals with and without type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus is highly prevalent in obese individuals. Bariatric surgery, promoted for reducing the medical problems of morbid obesity, has been increasingly recognized for its particular efficacy in treating diabetes. However, before bariatric surgery can be recommended for the treatment of diabetes, its safety in the diabetic population must be known. We assessed the odds of complications after bariatric surgery in patients with and without diabetes.

METHODS

This was a retrospective cohort study. Using an administrative database from 7 Blue Cross/Blue Shield plans, we identified 22,288 subjects who had undergone bariatric surgery from 2002 to 2008. From this cohort, we selected 6754 pairs of surgical patients (1 with and 1 without diabetes) matched by age, gender, health plan, and year of surgery. With conditional logistic regression analysis, we determined the relative odds of postoperative complications for ≤ 12 months after surgery in the 2 groups.

RESULTS

The mean age of the surgical patients was 46 years, and 79% were women. Postoperative complications were rare and comparable in those with and without diabetes. The most common complications were nausea, vomiting, and abdominal pain (8.8%), the need for a gastric revision procedure (5.0%), and upper endoscopy (2.3%). Select cardiac, infectious, and renal complications occurred more frequently in the diabetic group. The incidence of cardiac complications was greater in the 2-3-month and 4-6-month postoperative periods (odds ratio [OR] 1.7, P < .001), the incidence of infectious complications was greater in the 0-1-month (OR 1.3, P < .02) and 4-6-month (OR 1.8, P < .001) periods, and the incidence of renal complications was greater in the 2-3-month postoperative period (OR 4.6, P = .01).

CONCLUSIONS

Our findings support the safety of bariatric surgery in obese individuals with diabetes, although management strategies to avert postoperative cardiac, infectious, and renal complications in this population might be warranted.