Surgical Versus Medical Treatment of Type 2 Diabetes Mellitus in Nonseverely Obese Patients: A Systematic Review and Meta-analysis

What Is Best for Weight Loss? A Comparative Review of the Safety and Efficacy of Bariatric Surgery Versus Glucagon-Like Peptide-1 Analogue

Obesity is a global health concern, necessitating effective weight-loss interventions. This study aimed to compare the efficacy and safety of semaglutide, a pharmacotherapeutic option, with bariatric surgery, a commonly utilized surgical intervention, for weight reduction. A systematic review of clinical trials, including the STEP (Semaglutide Treatment Effect in People) trials, sustain trials, pioneer trials, and the STAMPEDE (Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently) trial, was conducted to evaluate the outcomes of these interventions. The analysis of the clinical trials revealed that semaglutide demonstrated significant weight reduction in participants. However, adverse effects such as gastrointestinal (GI) disturbances, increased pulse rate, and rare cases of thyroid cancer were observed. Long-term effects showed partial weight regain and a return of certain cardiometabolic variables to baseline levels after semaglutide withdrawal. Comparatively, bariatric surgery, as demonstrated in the Longitudinal Assessment of Bariatric Surgery (LABS) consortium and supported by the STAMPEDE trial, exhibited higher efficacy in weight reduction and the management of obesity-induced complications such as diabetes. The STAMPEDE trial demonstrated that bariatric surgery, specifically Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), led to a significantly higher percentage of patients achieving desired diabetes treatment targets compared to medical therapy alone. While bariatric surgery showed superior efficacy, it also carried a higher risk of complications. In contrast, semaglutide presented a noninvasive alternative with significant weight reduction and lower incidences of adverse effects. In conclusion, this study highlights that bariatric surgery, such as Roux-en-Y gastric bypass and sleeve gastrectomy, remains a highly effective intervention for weight loss and management of obesity-induced complications. However, semaglutide represents a valuable noninvasive alternative, offering significant weight reduction and lower risks of adverse effects. The choice between these interventions should be based on individual patient characteristics and a comprehensive assessment of the risk-benefit profile.

Characteristics and outcomes for patients undergoing revisional bariatric surgery due to persistent obesity: a retrospective cohort study of 10,589 patients

BACKGROUND

Revisional bariatric surgery in an option for patients who experience weight regain or inadequate weight loss after primary elective bariatric procedures. However, there is conflicting data on safety outcomes of revisional procedures. We aim to characterize patient demographics, procedure type, and safety outcomes for those undergoing revisional compared to initial bariatric interventions to guide management of these patients.

METHODS

The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing primary elective to revisional bariatric procedures for inadequate weight loss. Bivariate analysis was performed to determine between group differences. Multivariable logistic regression determined factors associated with serious complications or mortality.

RESULTS

We evaluated 158,424 patients, including 10,589 (6.7%) revisional procedures. Patients undergoing revisional procedures were more like to be female (85.5% revisional vs. 81.0% initial; p < 0.001), had lower body mass index (43.6 ± 7.8 kg/m² revisional vs. 45.2 ± 7.8 kg/m² initial; p < 0.001), and less metabolic comorbidities than patients undergoing primary bariatric surgery. The most common revisional procedures were Roux-en-Y gastric bypass (48.4%) and sleeve gastrectomy (32.5%). Revisional procedures had longer operative duration compared to primary procedures. Patients undergoing revisional procedures were more likely to experience readmission to hospital (4.8% revisional vs. 2.9% initial; p < 0.001) and require reoperation (2.4% revisional vs. 1.0% initial; p < 0.001) within 30 days of the procedure. Revisional procedures were independently associated with increased serious complications (OR 1.49, CI 1.36-1.64, p < 0.001) but were not a significant predictor of 30-day mortality (OR 0.74, CI 0.36-1.50, p = 0.409).

CONCLUSIONS

In comparison to primary bariatric surgery, patients undergoing revisional procedures have less metabolic comorbidities. Revisional procedures have worse perioperative outcomes and are independently associated with serious complications. These data help to contextualize outcomes for patients undergoing revisional bariatric procedures and to inform decision making in these patients.

[Indications in Obesity Therapy - Surgeons First?]

Obesity is a growing problem worldwide. For the first time since 2010, more people have been overweight than underweight. In particular, obesity-associated diseases, above all type 2 diabetes mellitus, pose enormous challenges to the healthcare system. On July 3, 2020, the German Bundestag recognised obesity as a disease and initiated the development of a diseases management program (DMP), which is currently being drawn up. So far, the indication for treatment of obesity in Germany has been based on the S3 guideline "Surgery of obesity and metabolic diseases" of the DGAV from 2018 and the S3 guideline "Prevention and therapy of obesity" of the German Obesity Society e. V. from 2014. This article gives an overview of the currently available conservative, medical, endoscopic and surgical treatment methods for overweight and obesity in Germany and explains the indications. Against the background of the reorientation of obesity treatment as a part of the DMP and the forthcoming revisions of the guidelines, the previous indication should be discussed critically. The scientific findings of the last few years show that surgical treatment of obesity not only achieves the greatest weight loss in the long term, but also that obesity-associated diseases are then treated more effectively and overall mortality is reduced significantly more effectively than with conservative treatment.

Combined non-alcoholic fatty liver disease and type 2 diabetes in severely obese patients-medium term effects of sleeve gastrectomy versus Roux-en-Y-gastric bypass on disease markers

BACKGROUND

We aimed to evaluate the medium-term efficacy of sleeve gastrectomy (SG) vs. Roux-en-Y gastric bypass (RYGB) on remission of non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM).

METHODS

We identified severely obese patients [body mass index (BMI) >35 kg/m2] with NAFLD (as defined by the Longitudinal Assessment of Bariatric Surgery Study) and T2DM (as defined by the American Association of Clinical Endocrinologists and the American College of Endocrinology) who underwent SG or RYGB in a single university surgical centre. The cohorts were match-paired and data were analysed after at least 3 years of follow up. The key outcomes measured were: (I) the improvement of liver function tests and NAFLD markers; (II) glycemic control and insulin resistance.

RESULTS

Ninety-six patients were investigated; 44 (45.8%) were women. The mean pre-operative BMI was 45.2 kg/m2 in the SG and 42.0 kg/m2 in the RYGB group. SG and RYGB both significantly reduced serum liver enzyme concentrations. NAFLD markers resolved 2 years after SG in all patients. In contrast, only 78% and 80% of patients achieved remission of NAFLD 2 and 3 years after RYBG respectively. Both procedures resulted in comparable rates of remission of T2DM.

CONCLUSIONS

Bariatric surgery with SG may be preferable to RYGB for obese patients with NAFLD and T2DM based on the rates of remission of markers of these co-morbidities. However, our results need to be confirmed in prospective trials. Understanding the metabolic effects of specific bariatric surgical procedures may facilitate the development of a personalised approach to weight-loss surgery.

Two-year outcomes of Roux-en-Y gastric bypass vs medical treatment in type 2 diabetes with a body mass index lower than 32.5 kg/m2: a multicenter propensity score-matched analysis

BACKGROUND

Roux-en-Y gastric bypass (RYGB) has been widely reported to be safe and feasible, and has a powerful effect on improving metabolism and weight loss in patients with a high body mass index (BMI). A few studies have focused on the comparison of RYGB with medical treatment in type 2 diabetes (T2D) patients with a lower BMI.

OBJECTIVES

To compare the metabolic effects and safety of RYGB versus medical treatment during a 2 years follow-up in T2D patients with a BMI of 25 to 32.5 kg/m².

METHODS

This retrospective and multicenter cohort study participants were extracted from the T2D patients with a lower BMI (25-32.5 kg/m²) from three bariatric centers between 2009 and 2018. Propensity score matching (PSM) was used to minimize bias, and each patient in the surgical group was matched 1:2 to the patients in the medical group with the closest propensity score. Finally, 71 patients who received RYGB and 142 patients who underwent medical treatment with a 2 years follow-up were enrolled to compare the effects of RYGB and medical treatment. The primary endpoint was achievement of the triple endpoint (the simultaneous achievement of hemoglobin A1c (HbA1c) < 7.0%, fasting low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL (2.6 mmol/L), and systolic blood pressure (SBP) < 130 mmHg at the year-1 visit). Changes in weight, BMI, medication usage, complications, and adverse events were assessed.

RESULTS

In total, 213 patients (mean age of 47.4 ± 9.5 years, 70.4% male, mean BMI of 28.6 ± 2.2 kg/m²) were included in this study. At the end of the first year, 17 patients (23.9%) in the surgical group and 10 (7.0%) in the medical group had achieved the composite triple endpoint (OR 4.64; 95% CI 1.82-11.81; p = 0.001). Additionally, 43 patients (60.6%) in the surgical group and 11 patients (19.7%) in the medical group experienced remission of T2D. However, more complications were observed in the surgical group (36 vs. 22, p < 0.01).

CONCLUSIONS

Among T2D patients with a BMI between 25.0 and 32.5 kg/m², RYGB was more effective than medical treatment in resolving metabolic disorders and also resulted in more complications. The risk for complications should be considered in the clinical decision-making process for T2D patients with a low BMI.

Obesity Surgery Improves Hypogonadism and Sexual Function in Men without Effects in Sperm Quality

(1) Background: Obesity is associated with hypogonadism, sexual dysfunction, and impaired fertility in men. However, its effects on semen parameters or sexual function remain debatable. (2) Methods: This paper involves a longitudinal study in men submitted for obesity surgery at a university tertiary hospital. Patients were studied at baseline and at 6, 12, and 18 months after obesity surgery. At each visit, anthropometry measures were collected and hormonal and semen parameters were studied. Sexual function was evaluated with the International Index of Erectile Function (IIEF). (3) Results: A total of 12 patients were included. The average body mass index of patients decreased from 42.37 ± 4.44 to 29.6 ± 3.77 kg/m2 at 18 months after surgery (p < 0.05). Hormonal parameters improved after obesity surgery. The proportion of sperm cells with normal morphology tended to decrease from baseline and became most significant at 18 months (5.83 ± 4.50 vs. 2.82 ± 2.08). No significant changes were found in the remaining semen parameters. Erectile function improved significantly at six months after surgery. (4) Conclusions: The authors believe that, in general, the effects of obesity surgery on fertility may be limited or even deleterious (at least in the short and midterm follow-up).

Methodological appraisal of the evidence about efficacy of metabolic surgery in adults with non-morbid obesity and hypertension: An overview of systematic reviews

BACKGROUND

Nowadays, the high morbimortality of obesity is mainly related to diabetes, cancer, and hypertension. It is reported that obesity in patients with hypertension can lead to resistance to pressure reduction through pharmacological therapy and lifestyle changes, so bariatric surgery emerges as a proposed treatment for obesity.

METHODS

We performed an umbrella review that included systematic reviews of clinical trials that evaluated patients with hypertension and non-morbid obesity. The quality and certainty of the evidence was evaluated with the AMSTAR-II and GRADE tools.

RESULTS

677 systematic reviews were identified, of which only three were included for analysis. We considered the outcomes addressed by the reviews on hypertension, identifying that 5 RCTs evaluated pressure reduction at 1 year of follow-up and 5 RCTs at more than 1 year, 5 RCTs evaluated hypertension rate, 6 RCTs analyzed changes in systolic pressure and 5 RCTs changes in diastolic pressure. Likewise, when assessing the methodological quality, it was concluded that the three reviews have critically low quality.

CONCLUSIONS

We found only three systematic reviews that evaluated the topic with critically low methodological quality. They reported results in favor of metabolic surgery, but with very low certainty of evidence.

The Role of Beta Cell Recovery in Type 2 Diabetes Remission

Type 2 diabetes (T2D) has been considered a relentlessly worsening disease, due to the progressive deterioration of the pancreatic beta cell functional mass. Recent evidence indicates, however, that remission of T2D may occur in variable proportions of patients after specific treatments that are associated with recovery of beta cell function. Here we review the available information on the recovery of beta cells in (a) non-diabetic individuals previously exposed to metabolic stress; (b) T2D patients following low-calorie diets, pharmacological therapies or bariatric surgery; (c) human islets isolated from non-diabetic organ donors that recover from “lipo-glucotoxic” conditions; and (d) human islets isolated from T2D organ donors and exposed to specific treatments. The improvement of insulin secretion reported by these studies and the associated molecular traits unveil the possibility to promote T2D remission by directly targeting pancreatic beta cells.

Variation of Laparoscopic Roux-en-Y Gastric Bypass Techniques: a Survey of 518 Bariatric Surgeons

INTRODUCTION

Surgical technique varies dramatically in the performance of laparoscopic Roux-en-Y gastric bypass (LRYGB) and these differences can potentially lead to variation in outcomes. The objective of this study was to characterize surgical techniques used during LRYGB.

METHODS

An anonymous 44-question survey was distributed by email to all bariatric surgeons with membership in the ASMBS, SAGES, and ACS from April to June 2020. Questions were designed to evaluate surgeon demographics, experience, and variation of techniques. Only surgeons who performed LRYGB within the past year were included for analysis.

RESULTS

A total of 534 (18.8%) surgeons responded and the majority (97.0%) reported performing LRYGB in the past year. Surgeons were predominantly from the USA (77.8%). For preoperative work-up, 20.1% performed upper gastrointestinal series while 60.8% performed esophagogastroduodenoscopy. Limb length evaluation revealed mean Roux and biliopancreatic limb lengths of 124.1 ± 29.4 cm and 67.4 ± 32.2 cm, respectively. The gastrojejunostomy was most commonly formed using a linear stapler with handsewn closure of the common enterotomy (53.1%) and the jejunojejunostomy using a linear stapled anastomotic technique with handsewn closure of the common enterotomy (60.6%). The majority of surgeons closed the jejunojejunostomy mesenteric defect (91.1%) and one of the antecolic or retrocolic mesenteric defects (65.1%). Intraoperative leak tests were performed in 95.9% of cases. Only 22.1% of surgeons routinely performed upper gastrointestinal swallow studies postoperatively.

CONCLUSIONS

There are wide variations in pre- and intraoperative practice patterns for LRYGB. Further clinical trials designed to evaluate the impact of these practice pattern differences on patient outcomes are warranted.

Impact of Bariatric Surgery on Carotid Intima-Media Thickness in Patients with Morbid Obesity: a Prospective Study and Review of the Literature

BACKGROUND AND AIM

One of the main causes of mortality among obese patients is cardiovascular disease (CVD). Carotid intima-media thickness (CIMT) is an independent predictor for atherosclerosis and risk of CVD, and has been demonstrated to be related with obesity. This study aimed to evaluate the effect of substantial weight loss after bariatric surgery on CIMT.

METHODS

This prospective study was performed on patients with morbid obesity and standard indications for bariatric surgery in a tertiary referral center in Iran. The mean CIMT values were assessed using B-mode ultrasonography before and 6 months after bariatric surgery.

RESULTS

A total of 32 patients (25 females, 7 males) with a mean age of 38.18 ± 1.18 years were enrolled. Body mass index (BMI) was significantly reduced from 43.66 ± 6.44 to 29.01 ± 2.56 kg/m² during 6 months following surgery (p: 0.001). The mean CIMT values at 6 months after surgery were significantly lower than the baseline (0.53 ± 0.06 vs. 0.50 ± 0.08; p: 0.001). Along with a significant hypertension and metabolic syndrome remission, we observed considerable reduction in FBS (p: 0.019), cholesterol (p: 0.061), triglycerides (p: 0.001), and insulin levels (p: 0.001). Besides, liver stiffness was significantly decreased after surgery (6.15 ± 0.82 vs. 5.26 ± 0.83; p: 0.001). There was no statistically significant correlation between changes in quantitative variables and changes in CIMT.

CONCLUSION

Bariatric surgery results in significant reduction in CIMT, metabolic syndrome factors, and liver stiffness in patients with morbid obesity.

Development of a New Index Based on Preoperative Serum Lipocalin 2 to Predict Post-LSG Weight Reduction

Background

Bariatric surgery is the most effective therapy for obesity, but targeted weight reduction is not always achieved. Serum lipocalin-2 (LCN2) is closely associated with obesity, but its impact on weight loss after surgery is unknown. We aimed to access the reliability of LCN2 levels and other parameters as effective predictors of excellent weight loss (≥ 75% excess weight loss (EWL)) 1 year after bariatric surgery.

Methods

This retrospective study evaluated 450 patients (aged 18–65 years) with obesity at 3 months and 1 year after laparoscopic sleeve gastrectomy (LSG) surgery. Seventy-four patients who underwent LSG surgery and met the inclusion and exclusion criteria were included in this study. Serum LCN2, thyroid function, and metabolic and anthropometric parameters were assessed. Weight reduction was expressed as %EWL and percent total weight loss (%TWL) at 3 months and 1 year post surgery. Multivariable logistic regression analysis and receiver operating characteristic (ROC) curve analysis were used to evaluate predictors of ≥ 75%EWL.

Results

In our cohort, %EWL and %TWL were both strongly associated with preoperative serum LCN2 levels. The binary logistic regression analysis showed that preoperative LCN2, waist circumference, and glycated hemoglobin were independent predictors of excellent weight loss.

Conclusions

Based on these results, we determined a new P index with better predictive value for excellent weight reduction (≥ 75%EWL) 1 year after LSG surgery.

Graphical abstract

Diabetes Resolution at 10 Years After Biliopancreatic Diversion in Overweight and Class 1 Obese Patients with Type 2 Diabetes

Background

Long-term anti-diabetic effects of BPD in overweight or class 1 obese T2DM patients were investigated reporting the results at 10 years after BPD performed in severely non-obese T2DM patients.

Material and Methods

Thirty T2DM patients with BMI lower than 35 kg/m² were investigated at 1, 5, and 10 years after BPD, and the results are compared with those of 30 T2DM patients followed for 10 years on pharmacological and/or behavioral conventional therapy.

Results

Mean levels of fasting blood glucose (FBG) and serum glycated hemoglobin (HbA1_C) showed a marked reduction 1 year after BPD, values remaining slightly above the diabetic range throughout the entire follow-up. T2DM remission was observed in about 50% of the cases at 5 and 10 years after the operation. In 16 patients (53%), severe BPD-related complications developed, in ten cases requiring a surgical revision of the operation. In the BPD group, one patient died for malignant lymphoma and two patients after surgical revision. Within the control group, during the 10-year follow-up, no changes in the diabetic status were observed, being the FBG and HbA1_C mean values higher than those recorded in the BPD patients at any follow-up time. All T2DM subjects of the control group were alive at the end of the 10-year follow-up.

Conclusion

Despite satisfactory long-term metabolic outcomes, these data indicate that BPD should be used with caution as a metabolic procedure in the treatment of T2DM in overweight or class 1obese patients.

Graphical abstract

Five Years of MBSAQIP Data: Characteristics, Outcomes, and Trends for Patients with Super-obesity

PURPOSE

Incidence of super obesity (SO; BMI ≥ 50 kg/m²) is growing rapidly and confers worse metabolic complications than non-SO (BMI 30-50 kg/m²). We aim to characterize bariatric surgery patients with SO, their postoperative complications, and treatment trends over the last 5 years in hopes of informing SO-specific treatment protocols.

MATERIALS AND METHODS

The MBSAQIP database was analyzed, and two cohorts were compared, those with SO and non-SO. Univariate analysis was performed to determine between-group differences. Multivariable logistic regression analysis was performed to determine if SO was independently associated with serious complications or mortality.

RESULTS

We evaluated 751,952 patients with 173,110 (23.0%) having SO. Patients with SO were younger (42.2 ± 11.8 SO vs 45.1 ± 12.0 years non-SO, p < 0.001) and less likely to be female (74.8% vs 81.1%, p < 0.001). While comorbidities seem to be decreasing overall in bariatric surgery patients, those with SO have worse functional capacity and more endocrine, pulmonary, and vascular comorbidities. Patients with SO also have worse 30-day postoperative complications, and SO was independently associated with severe complications (OR 1.08; CI 1.05-1.11, p < 0.001) and mortality (OR 2.49; CI 2.12-2.92, p < 0.001) CONCLUSIONS: Patients with SO have significantly increased preoperative comorbidities resulting in worse postoperative outcomes. SO remains an independent risk factor for serious complications and the greatest independent risk factor for 30-day postoperative mortality. Considering the expected increase in patients with SO, substantial work is required to optimize bariatric surgery strategies specific to these patients.

Treating the Chronic Disease of Obesity

Obesity is a treatable chronic disease. Primary care providers play an essential role in diagnosis, treatment, and comprehensive care of patients with obesity. In recent years, treatment approaches have rapidly evolved, increasing effective and safe therapies. In this review, we provide practical information on the care of patients with obesity with a focus on antiobesity pharmacotherapy within the context of currently available therapeutic modalities such as intensive lifestyle interventions and bariatric surgery.

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Ultrasound-Targeted Microbubble Destruction Mediates Gene Transfection for Beta-Cell Regeneration and Glucose Regulation

Ultrasound-targeted microbubble destruction (UTMD) mediates gene transfection with high biosafety and thus has been promising toward treatment of type 1 diabetes. However, the potential application of UTMD in type 2 diabetes (T2D) is still limited, due to the lack of systematic design and dynamic monitoring. Herein, an efficient gene delivery system is constructed by plasmid deoxyribonucleic acid (DNA) encoding glucagon-like peptide 1 (GLP-1) in ultrasound-induced microbubbles, toward treatment of T2D in macaque. The as designed UTMD afforded enhancement of cell membrane penetration and GLP-1 expression in macaque, which is characterized by ultrasound-guided biopsy to monitor the dynamic process of islet cells for 6 months. Also, improvement of pancreatic beta cell regeneration, and regulation of plasma glucose in macaque with T2D is achieved. The approach would serve as promising alternatives for the treatment of T2D.

Synopsis of the 2020 U.S. VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

INTRODUCTION

In May of 2020, the U.S. Veterans Health Administration (VHA) and Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients who have overweight and obesity. This guideline is intended to give healthcare teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may have either of these conditions. It can be accessed at https://www.healthquality.va.gov/guidelines/CD/obesity/.

MATERIALS AND METHODS

In January of 2019, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines.

RESULTS

The guideline panel developed 12 key questions, systematically searched and evaluated the literature, created a 1-page algorithm, and advanced 18 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system.

CONCLUSIONS

This synopsis summarizes the key recommendations of the guideline regarding management of overweight and obesity, including referral to comprehensive lifestyle interventions that combine behavioral, dietary, and physical activity change, and additional tools of pharmacologic and procedural interventions. Additionally, recommendations based on evidence found in the literature for short-term weight loss are included. A clinical practice algorithm that is part of the guideline is also included. Additional materials, such as provider and patient summaries and a provider pocket card, are also available for public use, accessible at the U.S. Veterans Health Administration (VHA) Clinical Practice Guidelines (CPG) website listed above.

Incremental Net Monetary Benefit of Bariatric Surgery: Systematic Review and Meta-Analysis of Cost-Effectiveness Evidences

This systematic review aimed to comprehensively synthesize cost-effectiveness evidences of bariatric surgery by pooling incremental net monetary benefits (INB). Twenty-eight full economic evaluation studies comparing bariatric surgery with usual care were identified from five databases. In high-income countries (HICs), bariatric surgery was cost-effective among mixed obesity group (i.e., obesity with/without diabetes) over a 10-year time horizon (pooled INB = $53,063.69; 95% CI $42,647.96, $63,479.43) and lifetime horizon (pooled INB = $101,897.96; 95% CI $79,390.93, $124,404.99). All studies conducted among obese with diabetes reported that bariatric surgery was cost-effective. Also, the pooled INB for obesity with diabetes group over lifetime horizon in HICs was $80,826.28 (95% CI $32,500.75, $129,151.81). Nevertheless, no evidence is available in low- and middle-income countries.

The Formidable yet Unresolved Interplay between Endometriosis and Obesity

Obesity and endometriosis are two very common entities, yet there is uncertainty on their exact relationship. Observational studies have repeatedly shown an inverse correlation between endometriosis and a low body mass index (BMI). However, obesity does not protect against endometriosis and on the contrary an increased BMI may lead to more severe forms of the disease. Besides, BMI is not accurate in all cases of obesity. Consequently, other anthropometric and phenomic traits have been studied, including body adiposity content, as well as the effect of BMI early in life on the manifestation of endometriosis in adulthood. Some studies have shown that the phenotypic inverse correlation between the two entities has a genetic background; however, others have indicated that certain polymorphisms are linked with endometriosis in females with increased BMI. The advent of metabolic bariatric surgery and pertinent research have led to the emergence of biomolecules that may be pivotal in understanding the pathophysiological interaction of the two entities, especially in the context of angiogenesis and inflammation. Future research should focus on three objectives: detection and interpretation of obesity-related biomarkers in experimental models with endometriosis; integration of endometriosis-related queries into bariatric registries; and multidisciplinary approach and collaboration among specialists.

Laparoscopic Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy for Type 2 Diabetes Mellitus in Nonseverely Obese Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Recently, randomized controlled trials (RCTs) have indicated that bariatric surgery in nonseverely obese patients with a body mass index (BMI) less than 35 kg/m² might be even superior to medical therapy with regard to type 2 diabetes mellitus (T2DM) remission, but the efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) compared with laparoscopic sleeve gastrectomy (LSG) in nonseverely obese patients has not been conclusively determined. The objective of this study is to compare LRYGB versus LSG for T2DM in nonseverely obese patients.

METHODS

A meta-analysis identifying RCTs evaluating LRYGB versus LSG for T2DM in nonseverely obese patients was conducted. The primary outcome was T2DM remission. Additional analyses comprised percent excess weight loss (%EWL), BMI, waist circumference, hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), serum lipid level, medication use, quality of life, and adverse events.

RESULTS

Four RCTs concerning total 296 patients were included. T2DM remission rate and %EWL were of no difference between the two bariatric procedures. LRYGB was associated with lower BMI, waist circumference, low-density lipoprotein, and higher high-density lipoprotein than LSG. However, HbA1c, FPG, total cholesterol, and triglyceride were not significantly different between the two surgical groups. The medication use and quality of life were improved in both two groups. The gastroesophageal reflux diseases of LRYGB group were less than that of LSG group. Dumping syndromes were noted more frequently in the LRYGB group.

CONCLUSIONS

Both LRYGB and LSG have comparative effect on resolving T2DM in nonseverely obese patients at midterm follow-up. Further RCTs should address the potential risks and long-term effects of LRYGB and LSG in nonseverely obese patients.

Effect of Roux-en-Y Gastric Bypass for Patients with Type 2 Diabetes Mellitus and a BMI < 32.5 kg/m2: a 6-Year Study in Chinese Patients

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbidly obese patients to improve type 2 diabetes mellitus (T2DM). Recently, T2DM patients with a lower body mass index (BMI) have been receiving more attention, and these patients could benefit from RYGB.

METHODS

Fifty-two patients with T2DM underwent RYGB between October 2008 and December 2012 in our hospital. Weight, BMI, oral glucose tolerance test (OGTT), insulin release test (IRT), C-peptide release test (CRT), glycosylated hemoglobin (HbA1c), and lipid metabolic parameters were measured at baseline and at 3 and 6 months and 1, 2, 3, 4, 5, and 6 years after surgery.

RESULTS

The mean age of the 52 patients was 46.8 ± 9.5 years, and 57.7% were male. The mean duration of T2DM was 6.5 ± 4.6 years. Compared with the baseline values, weight and BMI were significantly decreased at several time points after surgery. HbA1c decreased from 8.2 ± 1.7% at baseline to 6.5 ± 1.4% at 3 months, 6.5 ± 1.4% at 6 months, 7.2 ± 1.3% at 4 years, and 7.5 ± 1.2% at 6 years. OGTT, OGTT-IRT, and OGTT-CRT improved after surgery. There was a decrease in triglycerides (TGs), total cholesterol (TC), and low-density lipoprotein (LDL) and an increase in high-density lipoprotein (HDL). At 6 years after surgery, 16.7% of patients achieved complete remission of T2DM, and 66.7% achieved improvement in T2DM.

CONCLUSION

RYGB may be a safe and effective treatment for T2DM patients with a BMI < 32.5 kg/m² in China. However, a long-term study without loss to follow-up is necessary for better evaluation.

Factors associated with resolution of type-2 diabetes mellitus after sleeve gastrectomy in obese adults

Many bariatric procedures are more effective for improving type-2 diabetes mellitus (T2DM) than conventional pharmacotherapy. The current research evaluated factors linked to complete and partial remission or improvement of T2DM after laparoscopic sleeve gastrectomy (LSG). The current prospective study included all diabetic patients who were submitted LSG between January 2015 and June 2018 and completed a 2-year follow-up period. Patients were assessed at baseline and 2 years after LSG. This work comprised of 226 diabetic cases. Two years after LSG, 86 patients (38.1%) achieved complete remission of DM, and 24 (10.6%) reached partial remission. Only 14 patients (6.2%) showed no change in their diabetic status. On univariate analysis, age ≤ 45 years, duration of diabetes ≤ 5 years, use of a single oral antidiabetic, HbA1c ≤ 6.5%, HOMA-IR ≤ 4.6, C-peptide > 2.72 ng/mL, and BMI ≤ 40 kg/m² predicted complete remission. The independent predictors of complete remission were age ≤ 45 years, duration of diabetes ≤ 5 years, use of a single oral antidiabetic, HOMA-IR ≤ 4.6, and C-peptide > 2.72 ng/mL. A combined marker of young age, short duration of DM, and low HOMA-IR predicted complete remission with sensitivity 93% and specificity 82%. Independent predictors of complete remission of T2DM after LSG were younger age, shorter duration, single oral antidiabetic, lower HOMA-IR, and higher C-peptide.

Type 2 diabetes mellitus status in obese patients following sleeve gastrectomy or one anastomosis gastric bypass

This study aims to compare sleeve gastrectomy (SG) and one anastomosis gastric bypass (OAGB) in terms of remission of type 2 diabetes mellitus (T2DM) in obese patients. All T2DM patients were followed-up for at least 36 months. The primary outcome was remission of T2DM. Secondary endpoints included weight reduction and the procedure’s impact on quality of life. In total, 53/1177 morbidly obese patients who underwent SG (Group A, n = 28) or OAGB (Group B, n = 25) had T2DM. Preoperatively, the mean Body Mass Index (BMI) values were 52.2 ± 8.5 kg/m² and 52.9 ± 10.9 kg/m² for Group A and Group B, respectively. Six patients in Group A were insulin dependent, while 8 were insulin dependent in Group B. After 36 months, diabetes remission was achieved by only 10 patients (35.7%) in Group A. However, in Group B, 22 patients (88%) remained off antidiabetic agents (p < 0.0001), with ΔHbA1c (%) reaching 1.4 ± 1.5% in Group A and 2.7 ± 2.1% in Group B (p = 0.02). Excess weight loss% (%EWL) was again significantly different between the two groups (MA = 79.8 ± 14.5%, MB = 93.3 ± 16.0%, p = 0.003). OAGB is more effective in improving glycaemic control and %EWL, with almost immediate resolution of diabetes, as well as long-term weight loss.

Impact of Metabolic Surgery on Type-2 Diabetes Remission

Diabetes Mellitus is characterized by numerous metabolic disorders, which have in common the serum elevation of glucose, caused for a pancreatic malfunction in insulin secretion and / or its action. It is a non-communicable disease, considered major public health problems and generalized growth worldwide, being a chronic disease, which can generate a high treatment cost. Metabolic surgery is a safe treatment, regulated by the Federal Council of Medicine and useful in treating people with BMI over 30 years of age, who are unable to control pathologies associated with obesity, primarily type 2 diabetes. The general objective of this study is to understand through a literature review the main impacts of metabolic surgery about the remission of DM 2. This present study it is an exploratory and descriptive study carried out through a literature review. Data were collected through research in virtual health databases, at the Virtual Health Library - VHL, Latin American and Caribbean Health Sciences Information System, LILACS, National Library of Medicine - MEDLINE, Scielo, USP database, PUBMED theses and books. Metabolic surgery proof be a good and effective treatment for having and maintaining good weight loss, as well as a significant clinical and metabolic improvement that extends beyond weight loss. Metabolic surgery is a satisfactory way of achieving long-term weight reduction in obese individuals, increasing survival for these patients. Obese patients with DM2 have a long-term remission of DM2 after bariatric / metabolic surgery. Therefore, it concludes that such procedure is effective in the treatment of the disease and other diseases associated with obesity.

Weight Loss and Serum Lipids in Overweight and Obese Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Excess adipose tissue is associated with an abnormal lipid profile that may improve with weight reduction. In this meta-analysis, we aimed to estimate the magnitude of change in lipid parameters associated with weight loss in adults who are overweight or obese.

METHODS

We searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus from 2013 to September, 2018. We included randomized controlled trials (RCTs) that evaluated interventions to treat adult obesity (lifestyle, pharmacologic and surgical) with follow-up of 6 months or more.

RESULTS

We included 73 RCTs with moderate-to-low risk of bias, enrolling 32 496 patients (mean age, 48.1 years; weight, 101.6 kg; and body mass index [BMI], 36.3 kg/m2). Lifestyle interventions (diet, exercise, or both), pharmacotherapy, and bariatric surgery were associated with reduced triglyceride (TG) and low-density lipoprotein cholesterol (LDL-C) concentrations and increased high-density lipoprotein cholesterol (HDL-C) at 6 and 12 months. The following data are for changes in lipid parameters after 12 months of the intervention with 95% CI. Following lifestyle interventions, per 1 kg of weight lost, TGs were reduced by -4.0 mg/dL (95% CI, -5.24 to -2.77 mg/dL), LDL-C was reduced by -1.28 mg/dL (95% CI, -2.19 to -0.37 mg/dL), and HDL-C increased by 0.46 mg/dL (95% CI, 0.20 to 0.71 mg/dL). Following pharmacologic interventions, per 1 kg of weight lost, TGs were reduced by -1.25 mg/dL (95% CI, -2.94 to 0.43 mg/dL), LDL-C was reduced by -1.67 mg/dL (95% CI, -2.28 to -1.06 mg/dL), and HDL-C increased by 0.37 mg/dL (95% CI, 0.23 to 0.52 mg/dL). Following bariatric surgery, per 1 kg of weight lost, TGs were reduced by -2.47 mg/dL (95% CI, -3.14 to -1.80 mg/dL), LDL-C was reduced by -0.33 mg/dL (95% CI, -0.77 to 0.10 mg/dL), and HDL-C increased by 0.42 mg/dL (95% CI, 0.37 to 0.47 mg/dL). Low-carbohydrate diets resulted in reductions in TGs and increases in HDL-C, whereas low-fat diets resulted in reductions in TGs and LDL-C and increases in HDL-C. Results were consistent across malabsorptive and restrictive surgery.

CONCLUSIONS

Weight loss in adults is associated with statistically significant changes in serum lipids. The reported magnitude of improvement can help in setting expectations, inform shared decision making, and facilitate counseling.

Changes in Bone Mineral Density After Weight Loss Due to Metabolic Surgery or Lifestyle Intervention in Obese Patients

PURPOSE

Metabolic surgery and lifestyle intervention are two common methods used to treat obesity, but the effects of weight loss on bone mineral density (BMD) remain controversial. Our aim was to evaluate changes in BMD of the total hip, femoral neck, and lumbar spine after weight loss caused by metabolic surgery or lifestyle intervention.

MATERIALS AND METHODS

We searched PubMed, Web of Science, and the Cochrane Library to identify relevant studies published before 5 August 2020. The primary outcomes, including the BMD of the total hip, femoral neck, and lumbar spine before and 12 months after metabolic surgery or lifestyle intervention, were extracted.

RESULTS

A total of 19 studies with 1095 participants with obesity were included. Among them, 603 participants with obesity accepted metabolic surgery, while 492 accepted lifestyle intervention. At 12 months after weight loss, the BMD of the total hip decreased significantly in obese patients (mean difference [MD] = 0.06 g/cm²; 95% confidence interval [CI] 0.03 to 0.08; I² = 67%; P < 0.001), while the BMD of the lumbar spine did not significantly change (P > 0.05). In the subgroup analysis, the BMD of the femoral neck decreased significantly at 12 months in obese patients who underwent metabolic surgery (MD = 0.08 g/cm²; 95% CI 0.04 to 0.13; I² = 84%; P < 0.001), while it did not significantly change in obese patients who underwent lifestyle treatment (P > 0.05).

CONCLUSION

Regardless of whether the patients underwent metabolic surgery or lifestyle treatment, the BMD of the total hip significantly decreased in obese patients after weight loss. Different methods used to lose weight may have different effects on the BMD of the femoral neck. Prospective studies, preferably randomized controlled trials (RCTs), are still required to investigate whether the effects of the two treatments on bone metabolism are truly different.

Comparative efficacy of bariatric surgery for type 2 diabetes mellitus: A protocol for systematic review and network meta-analysis

BACKGROUND

The comparative efficacy of bariatric surgical procedures for type 2 diabetes mellitus (T2DM) has not been completely elucidated. To investigate this question, we conduct a systematic review and network meta-analysis.

METHODS

The protocol followed preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) checklist. Two review authors will independently search the PubMed, Embase (Ovid), and the Cochrane Central Register of Controlled Trials databases. The primary outcome is T2DM remission. The secondary outcomes include BMI, HbA1c (%), and percentage excess weight loss (% EWL). Results from the network meta-analysis will be presented as summary relative effect sizes (WMD or RR) and relative 95% CIs for each possible pair of treatments. Outcomes will be combined based on different periods of follow-up (12 months, 36 months, and 60 months).

RESULTS

The results will provide useful information about the efficacy of bariatric surgical procedures in patients with T2DM.

CONCLUSION

The findings of the study will be disseminated through peer-reviewed journal.

INPLASY REGISTRATION NUMBER

INPLASY202050053.

Defining remission of type 2 diabetes in research studies: A systematic scoping review

BACKGROUND

Remission has been identified as a top priority by people with type 2 diabetes. Remission is commonly used as an outcome in research studies; however, a widely accepted definition of remission of type 2 diabetes is lacking. A report on defining remission was published (but not formally endorsed) in Diabetes Care, an American Diabetes Association (ADA) journal. This Diabetes Care report remains widely used. It was the first to suggest 3 components necessary to define the presence of remission: (1) absence of glucose-lowering therapy (GLT); (2) normoglycaemia; and (3) for duration ≥1 year. Our aim is to systematically review how remission of type 2 diabetes has been defined by observational and interventional studies since publication of the 2009 report.

METHODS AND FINDINGS

Four databases (MEDLINE, EMBASE, Cochrane Library, and CINAHL) were searched for studies published from 1 September 2009 to 18 July 2020 involving at least 100 participants with type 2 diabetes in their remission analysis, which examined an outcome of type 2 diabetes remission in adults ≥18 years and which had been published in English since 2009. Remission definitions were extracted and categorised by glucose-lowering therapy, glycaemic thresholds, and duration. A total of 8,966 titles/abstracts were screened, and 178 studies (165 observational and 13 interventional) from 33 countries were included. These contributed 266 definitions, of which 96 were unique. The 2009 report was referenced in 121 (45%) definitions. In total, 247 (93%) definitions required the absence of GLT, and 232 (87%) definitions specified numeric glycaemic thresholds. The most frequently used threshold was HbA1c<42 mmol/mol (6.0%) in 47 (20%) definitions. Time was frequently omitted. In this study, a total of 104 (39%) definitions defined time as a duration. The main limitations of this systematic review lie in the restriction to published studies written in English with sample sizes of over 100. Grey literature was not included in the search.

CONCLUSIONS

We found that there is substantial heterogeneity in the definition of type 2 diabetes remission in research studies published since 2009, at least partly reflecting ambiguity in the 2009 report. This complicates interpretation of previous research on remission of type 2 diabetes and the implications for people with type 2 diabetes. Any new consensus definition of remission should include unambiguous glycaemic thresholds and emphasise duration. Until an international consensus is reached, studies describing remission should clearly define all 3 components of remission.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019144619.

The SEEN comprehensive clinical survey of adult obesity: Executive summary

Obesity is one of the great challenges in healthcare nowadays with important implications for health so requiring comprehensive management. This document aims to establish practical and evidence-based recommendations for the diagnosis and management of in Spain, from the perspective of the clinical endocrinologist. A position statement has been made that can be consulted at www.seen.es, and that has been agreed by the Obesity Group of the Spanish Society of Endocrinology and Nutrition (GOSEEN), together with the Nutrition Area (NutriSEEN) and the Working Group of Endocrinology, Nutrition and Physical Exercise (GENEFSEEN).

Benefits and Risks of Bariatric Surgery in Adults: A Review

Importance

Severe obesity and its related diseases, such as type 2 diabetes, hypertension, dyslipidemia, and sleep apnea, are very common in the United States, but currently very few patients with these conditions choose to undergo bariatric surgery. Summaries of the expanding evidence for both the benefits and risks of bariatric surgery are needed to better guide shared decision-making conversations.

Observations

There are approximately 252 000 bariatric procedures (per 2018 numbers) performed each year in the US, of which an estimated 15% are revisions. The 1991 National Institutes of Health guidelines recommended consideration of bariatric surgery in patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 40 or higher or 35 or higher with serious obesity-related comorbidities. These guidelines are still widely used; however, there is increasing evidence that bariatric procedures should also be considered for patients with type 2 diabetes and a body mass index of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment for type 2 diabetes. Substantial evidence indicates that surgery results in greater improvements in weight loss and type 2 diabetes outcomes, compared with nonsurgical interventions, regardless of the type of procedures used. The 2 most common procedures used currently, the sleeve gastrectomy and gastric bypass, have similar effects on weight loss and diabetes outcomes and similar safety through at least 5-year follow-up. However, emerging evidence suggests that the sleeve procedure is associated with fewer reoperations, and the bypass procedure may lead to more durable weight loss and glycemic control. Although safety is a concern, current data indicate that the perioperative mortality rates range from 0.03% to 0.2%, which has substantially improved since early 2000s. More long-term randomized studies are needed to assess the effect of bariatric procedures on cardiovascular disease, cancer, and other health outcomes and to evaluate emerging newer procedures.

Conclusions and Relevance

Modern bariatric procedures have strong evidence of efficacy and safety. All patients with severe obesity-and especially those with type 2 diabetes-should be engaged in a shared decision-making conversation about the risks and benefits of surgery compared with continuing usual medical and lifestyle treatment, and the decision about surgery should be driven primarily by informed patient preferences.

Metabolic surgery for the treatment of type 2 diabetes: A network meta-analysis of randomized controlled trials

AIM

To compare different types of metabolic surgery (MS) with medical therapy (MT) for the treatment of type 2 diabetes (T2D).

MATERIALS AND METHODS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different MS techniques versus MT in people with T2D, with a duration of ≥24 weeks. Primary endpoints were glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and diabetes remission. Indirect comparisons of different types of surgery were performed by NMA. Mean and 95% confidence intervals for continuous variables, and Mantel-Haenzel odds ratios for categorial variables, were calculated using random effect models. Types of MS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); and duodenojejunal bypass.

RESULTS

The 24 retrieved trials included 1351 patients (1014 with MS and 337 with MT). The mean baseline BMI was 36.8 kg/m² . MS was associated with significantly greater reductions in HbA1c and FPG and greater diabetes remission when compared to MT. In the NMA, a significant reduction in HbA1c was observed with OAGB and SG. All surgical procedures were associated with a significant increase in diabetes remission, except GCP and LAGB. All procedures were associated with a reduction of body mass index (BMI).

CONCLUSIONS

Metabolic surgery is an interesting option for the treatment of T2D, although further data are needed to demonstrate its long-term efficacy and safety. Present data are not sufficient to modify current recommendations, which consider MS a possible treatment for T2D in those with a BMI >35 kg/m² .

Future of Bariatric Embolization: A Review of Up-to-date Clinical Trials

Obesity is a significant health issue with an overall rise in mortality; it has multiple risk factors, including hormonal effects, which play a significant role in the balance of food intake and weight gain. Ghrelin is an anabolic hormone secreted from stomach fundus and plays a significant role in this regulation. Management of obesity involves multiple interventions, including lifestyle adjustment, pharmacotherapy, and bariatric surgery. Bariatric embolization is a relatively new procedure; several animal studies show that embolization of the left gastric artery reduces serum ghrelin and induces weight loss.  Also, several clinical studies were conducted in the past ten years which have shown bariatric embolization's effectiveness in inducing weight loss: a meta-analysis of 47 patients included in six different clinical studies of left gastric artery embolization resulted in 8% total weight loss from baseline body weight. Many studies also show this procedure's effect on lowering the HgA1C level and lipid profile. Clinical studies mostly reported minor adverse effects such as transient abdominal discomfort, nausea and vomiting, gastric ulcers, and major adverse effects were uncommon, suggesting the procedure is well tolerated. It may be an alternative line of management in patients who are not suitable candidates for bariatric surgery. Although future clinical studies will provide an answer to several questions like the exact effects of the procedure on diabetes and metabolic syndrome, future studies are also needed to establish particular guidelines to match different patient characteristics with their optimal procedural techniques and pre- and post-procedure evaluation tests.

Analysis of Predictors of Type 2 Diabetes Mellitus Remission After Roux-en-Y Gastric Bypass in 101 Chinese Patients

BACKGROUND

To investigate prognostic factors for complete remission in type 2 diabetes mellitus (T2DM) patients who underwent gastric bypass (GBP) and to establish a prognostic model for risk stratification.

METHODS

We evaluated the baseline clinical features of patients with T2DM who received at Beijing Tian Tan Hospital from April 2012 to December 2015. Complete remission of T2DM was defined as meeting the following criteria: HbA1c < 6.5%, fasting plasma glucose (FPG) < 100 mg/dL, and absence of hypoglycemic drugs for 1 year following GBP.

RESULTS

A total of 101 patients were enrolled in our study, and the complete remission rate of T2DM was 70.3% (71/101). Compared with patients with incomplete remission, patients with complete remission of T2DM had higher C-peptide levels, lower HbA1c, shorter disease duration, better β cell function, and an absence of insulin therapy. HbA1c level, fasting C-peptide, duration of T2DM, and history of medical therapy were important prognostic factors for complete remission of T2DM (P = 0.001, 0.002, 0.01, 0.028, respectively). Patients with HbA1c lower than 7.5%, a history of T2DM shorter than 9.5 years, fasting C-peptide higher than 1.2 ng/mL, and absence of insulin therapy before GBP achieved a higher complete remission rate of T2DM after GBP (AUC of the model was 0.825, 95% CI, 0.741-0.910; P = 0.001).

CONCLUSIONS

The duration of T2DM, history of medical therapy, and levels of HbA1c and fasting C-peptide are independent predictors for the prognosis of T2DM patients undergoing GBP. Patients with HbA1c lower than 7.5%, a history of T2DM shorter than 9.5 years, a fasting C-peptide higher than 1.2 ng/mL, and an absence of insulin therapy may have a higher complete remission rate of T2DM after GBP.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

The Impact of Roux-en-Y Gastric Bypass on Bone Remodeling Expressed by the P1NP/βCTX Ratio: a Single-Center Prospective Cohort Study

BACKGROUND

Bariatric surgery seems to decrease bone mineral density and increase the risk of fatigue fractures. P1NP (bone formation) and βCTX (bone resorption) were recently validated as reference bone turnover markers (BTM).

OBJECTIVE

To assess changes in bone remodeling in severely obese patients undergoing Roux-en-Y gastric bypass (RYGB) by using a new composite biomarker, the P1NP/βCTX ratio.

METHODS

We prospectively collected blood samples preoperatively, at 1 month and at 1 year from 114 consecutive RYGB patients from 12/2012 to 04/2014. Repeated measures ANOVA and multiple regression were used for data analysis. Cumulative incidence of fractures was assessed in 06/2018.

RESULTS

The P1NP/βCTX ratio decreased significantly (P < 0.001) from baseline to 1 month and 1 year (180 ± 6.6, 110 ± 4.1, and 132 ± 5.4). The 1-year P1NP/βCTX ratio did not correlate with BMI or ΔBMI, but inversely correlated with age (r = - 0.23, P = 0.014) and with hsCRP (r = - 0.26, P = 0.009), even after adjustment for age, sex, BMI, and lifestyle, and linearly correlated with albumin (r = 0.2, P = 0.037). At baseline, none of these correlations were detectable. Serum for all time-points was available from > 94% of the patients. At a median follow-up of 4.7 years, 8 patients (7.3%) had a bone fracture, all of them traumatic.

CONCLUSION

Following RYGB, bone remodeling increases, with a shift toward degradation. This effect seems to be weight-loss independent and shows a correlation with age, with the level of systemic inflammation, and with nutritional state. The risk of fractures should be assessed systematically in bariatric patients and measures of prevention should be improved accordingly.

A modified AUGIS Delphi process to establish research priorities in bariatric and metabolic surgery

Delphi methodology may be utilized to develop consensus opinion among a group of experts. The aim of our study was to use a modified Delphi process to determine the future research priorities among bariatric and metabolic healthcare professionals in the United Kingdom. Members of the Association of Upper Gastrointestinal Surgeons and the British Obesity and Metabolic Surgery Society were invited to submit individual research questions via an online survey (phase I). Two rounds of prioritization by multidisciplinary expert healthcare professionals (phase II and III) were completed to determine a final list of high-priority research questions. Fifty-one bariatric and metabolic surgery-focused questions were identified in phase I. Thirty-five questions were taken forward for prioritization in phase II. Eleven high-priority questions were identified in phase III. The final list of high-priority questions had an emphasis on the pathophysiology and long-term sequelae of bariatric and metabolic surgery. A modified Delphi process has produced a list of 11 high-priority research questions in bariatric and metabolic surgery. Future studies and awards from funding bodies should reflect this consensus list of prioritized questions in the interest of improving patient care and encouraging collaborative research across multiple centres.

The Role of Bariatric Surgery on Diabetes and Diabetic Care Compliance

PURPOSE OF REVIEW

Bariatric surgery is a durable and long-term solution to treat both obesity and its associated comorbidities, specifically type 2 diabetes mellitus (T2DM). Many studies have demonstrated the benefits of bariatric surgery on T2DM, but weight recidivism along with recurrence of comorbidities can be seen following these procedures. Patient compliance post-bariatric surgery is linked to weight loss outcomes and comorbidity improvement/resolution. The role of compliance with respect to T2DM medication in bariatric patients specifically has not recently been examined. This article seeks to review the role of bariatric surgery on short- and long-term resolution of T2DM, recurrence, and compliance with T2DM medication following bariatric surgery.

RECENT FINDINGS

Seven randomized control trials have examined metabolic surgery versus medical therapy in glycemic control in patients meeting criteria for severe obesity. Six out of seven studies demonstrate a significant advantage in the surgical arms with regards to glycemic control, as well as secondary endpoints such as weight loss, serum lipid levels, blood pressure, renal function, and other parameters. While patient compliance with lifestyle modifications post-bariatric surgery is linked to weight loss outcomes, there are no studies to date that directly evaluate the role of lifestyle modifications and T2DM medication adherence in the management of T2DM post-bariatric surgery. Bariatric surgery is an effective treatment option to achieve long-term weight loss and resolution of obesity-related medical comorbidities, specifically T2DM. Patient compliance to lifestyle modifications post-bariatric surgery is linked to weight loss outcomes and comorbidity resolution. The role of diabetic care compliance in bariatric patient outcomes, however, is poorly understood. Further studies are needed to elucidate the predictors and associated risk factors for non-compliance in this patient population.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Metabolic Surgery and Diabesity: a Systematic Review

Bariatric surgery is used to induce weight loss (baros = weight). Evidence has shown that bariatric surgery improves the comorbid conditions associated with obesity such as hypertension, hyperlipidemia, and type 2 diabetes mellitus T2DM. Hence, shifting towards using metabolic surgery instead of bariatric surgery is currently more appropriate in certain subset of patients. Endocrine changes resulting from operative manipulation of the gastrointestinal tract after metabolic surgery translate into metabolic benefits with respect to the comorbid conditions. Other changes include bacterial flora rearrangement, bile acids secretion, and adipose tissue effect. The aim of this systematic review is to examine clinical trials regarding long-term effects of bariatric and metabolic surgery on patients with T2DM and to evaluate the potential mechanisms leading to the improvement in the glycaemic control.

Obesity Surgery and the Treatment of Metabolic Diseases

BACKGROUND

3.9% of men and 5.2% of women in Germany suffer from second-degree obesity (body mass index [BMI] ≥ 35 to <40 kg/m2), and 6.5 million persons suffer from diabetes. Obesity surgery has become established as a further treatment option alongside lifestyle changes and pharmacotherapy.

METHODS

The guideline was created by a multidisciplinary panel of experts on the basis of publications retrieved by a systematic literature search. It was subjected to a formal consensus process and tested in public consultation.

RESULTS

The therapeutic aims of surgery for obesity and/or metabolic disease are to improve the quality of life and to prolong life by countering the life-shortening effect of obesity and its comorbidities. These interventions are superior to conservative treatments and are indicated when optimal non-surgical multimodal treatment has been tried without benefit, in patients with BMI ≥ 40 kg/m², or else in patients with BMI ≥ 35 kg/m² who also have one or more of the accompanying illnesses that are associated with obesity. A primary indication without any prior trial of conservative treatment exists if the patient has a BMI ≥ 50 kg/m², if conservative treatment is considered unlikely to help, or if especially severe comorbidities and sequelae of obesity are present that make any delay of surgical treatment inadvisable. Metabolic surgery for type 2 diabetes is indicated (with varying recommendation grades) for patients with BMI ≥ 30 kg/m², and as a primary indication for patients with BMI ≥ 40 kg/m². The currently established standard operations are gastric banding, sleeve gastrectomy, proximal Roux-en-Y gastric bypass, omega-loop gastric bypass, and biliopancreatic diversion.

CONCLUSION

No single standard technique can be recommended in all cases. In the presence of an appropriate indication, the various surgical treatment options for obesity and/or metabolic disease should be discussed with the patient.

[Metabolic surgery]

In recent years the surgical treatment of metabolic diseases has become established as an effective alternative to conservative treatment. The new S3 guidelines address these changes and give clear indications for obesity surgery. One of the core points of the new guidelines is the differentiation between obesity surgery and metabolic surgery. In obesity surgery the primary aim of treatment is weight loss whereas for metabolic indications the aim is an improvement of comorbidities independent of the body mass index (BMI). With respect to the selection of procedures sleeve gastrectomy (SG) and the traditional Roux-en-Y gastric bypass (RYGB) can be used as safe and evidence-based operative procedures. The RYGB has better metabolic effects but higher complication and reintervention rates. More recent procedures, such as the one anastomosis gastric bypass (OAGB) and single anastomosis duodeno-ileal (SADI) bypass possibly have slightly stronger metabolic effects, however, the risk of malnutrition and vitamin deficiency is higher.

Factors influencing long-term weight loss after bariatric surgery

BACKGROUND

Bariatric surgery provides sustained weight loss and improves comorbidities. However, long term data has shown that patients gradually regain weight after 1 year. Several factors have been associated with poor weight loss after bariatric surgery.

OBJECTIVE

Our goal is to investigate factors associated with poor weight loss following laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

SETTING

Military academic medical center.

METHODS

Retrospective review of 247 patients who underwent laparoscopic SG or RYGB between 2010-2012 at Eisenhower Army Medical Center and followed for 5 years postoperatively. Factors of age, type of surgery, sex, hypertension, depression, and type 2 diabetes (T2D) are analyzed in univariate and multivariate analysis with percent total weight loss (%TWL) and Body Mass Index (BMI) change as primary endpoints measured at 3 and 5 years.

RESULTS

Average BMI change are maximized at 1 year and decreased at 3 and 5 years post-surgery. Age, diabetes, hypertension and type of surgery significantly influenced weight loss at 3 and 5 years on univariate analysis. However, patients with diabetes, hypertension and sleeve gastrectomy were significantly older than comparable control group. Multivariable analysis showed that age and type of surgery, not diabetes or hypertension, were associated with poor %TWL and BMI change at 3 and 5 years.

CONCLUSION

While presence of hypertension and diabetes initially appeared to be associated with weight recidivism, their impacts were negligible on multivariable analysis. However, age and sleeve gastrectomy are independent risk factors. Our data can be used to counsel patients on expected weight loss after bariatric surgery.

Comorbidities as an Indication for Metabolic Surgery

Metabolic diseases, comprising type 2 diabetes mellitus (T2DM), dyslipidemia, and non-alcoholic steatohepatitis (NASH), are rapidly increasing worldwide. Conservative medical therapy, including the newly available drugs, has only limited effects and does neither influence survival or the development of micro- or macrovascular complications, nor the progression of NASH to liver cirrhosis, nor the development of hepatocellular carcinomas in the NASH liver. In contrast, metabolic surgery is very effective independent of the preoperative body mass index (BMI) in reducing overall and cardiovascular mortality in patients with T2DM. Furthermore, metabolic surgery significantly reduces the development of micro- and macrovascular complications while being the most effective therapy in order to achieve remission of T2DM and to reach the targeted glycemic control. Importantly, even existing diabetic complications such as nephropathy as well as the features of NASH can be reversed by metabolic surgery. Here, we propose indications for metabolic surgery due to T2DM and NASH based on a simple but objective, disease-specific staging system. We outline the use of the Edmonton Obesity Staging System (EOSS) as a clinical staging system independent of the BMI that will identify patients who will benefit the most from metabolic surgery.