Gastric bypass in Type 2 diabetes with BMI < 30: weight and weight loss have a major influence on outcomes

Comparison of various prediction models in the effect of laparoscopic sleeve gastrectomy on type 2 diabetes mellitus in the Chinese population 5 years after surgery

BACKGROUND

The effect of bariatric surgery on type 2 diabetes mellitus (T2DM) control can be assessed based on predictive models of T2DM remission. Various models have been externally verified internationally. However, long-term validated results after laparoscopic sleeve gastrectomy (LSG) surgery are lacking. The best model for the Chinese population is also unknown.

METHODS

We retrospectively analyzed Chinese population data 5 years after LSG at Beijing Shijitan Hospital in China between March 2009 and December 2016. The independent t -test, Mann-Whitney U test, and chi-squared test were used to compare characteristics between T2DM remission and non-remission groups. We evaluated the predictive efficacy of each model for long-term T2DM remission after LSG by calculating the area under the curve (AUC), sensitivity, specificity, Youden index, positive predictive value (PPV), negative predictive value (NPV), and predicted-to-observed ratio, and performed calibration using Hosmer-Lemeshow test for 11 prediction models.

RESULTS

We enrolled 108 patients, including 44 (40.7%) men, with a mean age of 35.5 years. The mean body mass index was 40.3 ± 9.1 kg/m 2 , the percentage of excess weight loss (%EWL) was (75.9 ± 30.4)%, and the percentage of total weight loss (%TWL) was (29.1± 10.6)%. The mean glycated hemoglobin A1c (HbA1c) level was (7.3 ± 1.8)% preoperatively and decreased to (5.9 ± 1.0)% 5 years after LSG. The 5-year postoperative complete and partial remission rates of T2DM were 50.9% [55/108] and 27.8% [30/108], respectively. Six models, i.e., "ABCD", individualized metabolic surgery (IMS), advanced-DiaRem, DiaBetter, Dixon et al' s regression model, and Panunzi et al 's regression model, showed a good discrimination ability (all AUC >0.8). The "ABCD" (sensitivity, 74%; specificity, 80%; AUC, 0.82 [95% confidence interval [CI]: 0.74-0.89]), IMS (sensitivity, 78%; specificity, 84%; AUC, 0.82 [95% CI: 0.73-0.89]), and Panunzi et al' s regression models (sensitivity, 78%; specificity, 91%; AUC, 0.86 [95% CI: 0.78-0.92]) showed good discernibility. In the Hosmer-Lemeshow goodness-of-fit test, except for DiaRem ( P <0.01), DiaBetter ( P <0.01), Hayes et al ( P = 0.03), Park et al ( P = 0.02), and Ramos-Levi et al' s ( P <0.01) models, all models had a satifactory fit results ( P >0.05). The P values of calibration results of the "ABCD" and IMS were 0.07 and 0.14, respectively. The predicted-to-observed ratios of the "ABCD" and IMS were 0.87 and 0.89, respectively.

CONCLUSION

The prediction model IMS was recommended for clinical use because of excellent predictive performance, good statistical test results, and simple and practical design features.

Type 2 diabetes remission after Roux-en-Y gastric bypass: a multicentered experience with long-term follow-up

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is associated with short- and mid-term type 2 diabetes (T2D) remission. Long-term outcomes and predictive parameters associated with remission following RYGB have not been well elucidated.

OBJECTIVE

Determining the overall long-term T2D remission rates following RYGB and identifying predictive variables associated with remission.

SETTING

Multicentered study including patients who underwent RYGB at 3 tertiary referral centers for bariatric surgery.

METHODS

We performed a retrospective cohort study between 2008-2017 to allow a minimum of 5 years of follow-up. We evaluated long-term T2D remission rates and annual T2D clinical and metabolic parameters up to 14 years after surgery. Predictors of remission were assessed using multivariate logistic regression. Patients were divided into 4 groups based on quartiles of total body weight loss percentage (%TBWL) to compare remission rates between groups.

RESULTS

A total of 815 patients were included (68.9% female, age 52.1 ± 11.5 yr; body mass index 45.1 ± 7.7 kg/m2) with a follow-up of 7.3 ± 3.8 years. Remission was demonstrated in 51% of patients. Predictors of remission included pre-operative duration of diabetes, baseline HbA1C, insulin use prior to surgery, number of antidiabetic medications and %TBWL (all P < .01). Remission rates were proportionally associated with %TBWL quartile (Q1, 40.9%; Q2, 52.7%; Q3, 53.1%; Q4, 56.1%) (P = .02).

CONCLUSIONS

Longer duration and higher severity of T2D were negatively associated with remission while higher %TBWL had a positive association. A significant proportion of patients in all quartiles experienced long-term remission after RYGB with a greater likelihood of remission correlated with greater weight loss.

Comparison of various prediction models in the effect of Roux-en-Y gastric bypass on type 2 diabetes in the Chinese population 5 years after surgery

BACKGROUND

Various prediction models of type 2 diabetes (T2D) remission have been externally verified internationally. However, long-term validated results after Roux-en-Y gastric bypass (RYGB) surgery are lacking. The best model for the Chinese population is also unknown.

OBJECTIVES

To evaluate the prediction effect of various prediction models on the long-term diabetes remission after RYGB in the Chinese population and to provide reference for clinical use.

SETTING

A retrospective clinical study at a university hospital.

METHODS

We retrospectively analyzed Chinese population data 5 years after RYGB and externally validated 11 predictive models to evaluate the predictive effect of each model on long-term T2D remission after RYGB.

RESULTS

We enrolled 84 patients. The mean body mass index was 41 kg/m2, and the percentage of excess weight loss (%EWL) was 72.3%. The mean glycated hemoglobin level was 8.4% preoperatively and decreased to 5.9% after 5 years. The 5-year postoperative complete and partial remission rates of T2D were 31% and 70.2%, respectively. The ABCD scoring model (sensitivity, 84%; specificity, 76%; area under the curve [AUC], .866) and the Panuzi et al. [34] study (sensitivity, 84%; specificity, 81%; AUC, .842) showed excellent results. In the Hosmer-Lemeshow goodness-of-fit test, calibration values for ABCD and Panuzi et al. [34] were .14 and .21, respectively. The predicted-to-observed ratios of ABCD and Panuzi et al. [34] were .83 and .88, respectively.

CONCLUSIONS

T2D was relieved to varying degrees 5 years after RYGB in patients with obesity. The prediction models in ABCD and the Panuzi et al. [34] studies showed the best prediction effects. ABCD was recommended for clinical use because of excellent predictive performance, good statistical test results, and simple and practical design features.

Predictors of T2DM Remission after Bariatric Surgery in Patients with a BMI < 35 kg/m2: a Meta-Analysis

PURPOSE

Although a few studies have reported the predictors of postoperative diabetes remission in patients with body mass index (BMI) < 35 kg/m2, the conclusions are still inconsistent. This meta-analysis aimed to evaluate the preoperative clinical factors of type 2 diabetes mellitus (T2DM) remission after bariatric surgery.

MATERIALS AND METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched until April 2022. The Newcastle-Ottawa Scale was used for quality assessment. Statistical heterogeneity was assessed with the I2 statistic, followed by subgroup and sensitivity analyses.

RESULTS

16 studies involving 932 patients were selected. T2DM remission was negatively correlated with age, duration, insulin use, fasting plasma glucose, fasting insulin, and glycosylated hemoglobin levels. While BMI, body weight, waist circumference, and C-peptide levels were positive predictors of T2DM remission in patients with a BMI < 35 kg/m2. However, there was no significant association between gender, oral hypoglycemic agent, homeostasis model assessment, high-density lipoprotein, low-density lipoprotein, total cholesterol, triglycerides, systolic blood pressure, diastolic blood pressure, and remission rate.

CONCLUSION

Patients with younger age, short diabetes duration, more obesity, better glucose control, and better β cell function were more likely to achieve T2DM remission in patients with a BMI < 35 kg/m2 after bariatric surgery.

Comparison of scoring systems for predicting remission of Type 2 diabetes in sleeve gastrectomy patients

Introduction: This study aims to compare the predictive capacity of ABCD, DiaRem2, Ad-DiaRem, and DiaBetter scoring systems for type 2 diabetes mellitus (T2DM) remission in Turkish adult morbidly obese patients who underwent SG.

Methods: This retrospective cohort study included 80 patients who underwent sleeve gastrectomy (SG) operation, were diagnosed with T2DM preoperatively, and had at least one-year follow-up after surgery. Because bariatric surgery is performed on patients with class III obesity (BMI ≥ 40 kg/m2) or class II obesity (BMI ≥ 35 kg/m2) with obesity releated comorbid conditions in our hospital, our study cohort consisted of these patients.

Results: The diagnostic performance of the DiaBetter, DiaRem2, Ad-DiaRem and ABCD for identifying diabetes remission, assessed by the AUC was 0.882 (95% CI, 0.807-0.958, p < 0.001), 0.862 (95% CI, 0.779-0.945, p < 0.001), 0.849 (95% CI, 0.766-0.932, p < 0.001) and 0.726 (95% CI, 0.601-0.851, p = 0.002), respectively. The AUCs of the Ad-Diarem, DiaBetter and DiaRem2 were statistically higher than AUC of the ABCD (all p-value < 0.001). Besides, there was no statistically significant difference in AUCs of the Ad-Diarem, DiaBetter and DiaRem scores (all p-value > 0.05).

Conclusion: Ad-Dairem, DiaBetter and DaiRem scoring systems were found to provide a successful prediction for diabetes remission in sleeve gastrectomy patients. It was observed that the predictive power of the ABCD scoring system was lower than the other systems. We think that the use of scoring systems for diabetes remission, which have a simple use, will become widespread.

Predictors of Type 2 Diabetes Mellitus Remission After Metabolic Surgery in Asian Patients with a BMI < 32.5 kg/m2

BACKGROUND

Metabolic surgery is an effective treatment for type 2 diabetes mellitus (T2DM) in patients with obesity. However, the efficacy in patients with body mass index (BMI) < 32.5 kg/m², especially in Asian populations, has not been widely reported, and there are few studies on the prediction of diabetes remission.

METHODS

We evaluated 112 patients with T2DM who underwent metabolic surgery between October 2008 and November 2019. The basic data of the patients were collected, and clinical variables were measured at 6 months, 1 year, and 2 years after metabolic surgery. Four independent predictors of surgical outcomes were identified to construct the prediction score.

RESULTS

Diabetes remission occurred for 38 of the 112 patients. Ninety patients underwent Roux-en-Y gastric bypass, while the remaining 22 patients underwent sleeve gastrectomy. Weight, glucose, and lipid metabolism parameters were improved significantly after metabolic surgery. Age, BMI, insulin use, and duration were independent predictors of T2DM remission. The above four factors were defined with scores and developed ABID (age, BMI, insulin use, duration) scoring system. Patients with greater ABID scores had a greater probability of diabetes remission (from 0% at score 0 to 100% at score 4).

CONCLUSIONS

The ABID score is a simple and easy-to-implement prediction score system of diabetes remission after metabolic surgery for T2DM patients with a BMI < 32.5 kg/m².

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.

Who will benefit from bariatric surgery for diabetes? A protocol for an observational cohort study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) and obesity are pandemic diseases that lead to a great deal of morbidity and mortality. The most effective treatment for obesity and T2DM is bariatric or metabolic surgery; it can lead to long-term diabetes remission with 4 in 10 of those undergoing surgery having normal blood glucose on no medication 1 year postoperatively. However, surgery carries risks and, additionally, due to resource limitations, there is a restricted number of patients who can access this treatment. Moreover, not all those who undertake surgery respond equally well metabolically. The objective of the current research is to prospectively investigate predictors of T2DM response following metabolic surgery, including those directly involved in its aetiopathogenesis such as fat distribution and genetic variants. This will inform development of a clinically applicable model to help prioritise this therapy to those predicted to have remission.

METHODS AND ANALYSIS

A prospective multicentre observational cohort study of adult patients with T2DM and obesity undergoing Roux-en-Y gastric bypass surgery. Patients will be comprehensively assessed before surgery to determine their clinical, metabolic, psychological, genetic and fat distribution profiles. A multivariate logistic regression model will be used to assess the value of the factors derived from the preoperative assessment in terms of prediction of diabetes remission.

ETHICS AND DISSEMINATION

Formal ethics review was undertaken with a favourable opinion (UK HRA RES reference number 18/LO/0931). The dissemination plan is to present the results at conferences, in peer-reviewed journals as well as to lay media and to patient organisations.

TRIAL REGISTRATION DETAILS

ClinicalTrials.gov, Identifier: NCT03842475.

Prediction of Long-Term Diabetes Remission After Metabolic Surgery in Obese East Asian Patients: a Comparison Between ABCD and IMS Scores

PURPOSE

Recently, more than 10 models have been developed to predict remission of type 2 diabetes mellitus (T2DM) after metabolic surgery. The ABCD score was compared to the individualized metabolic surgery (IMS) score in terms of prediction of T2DM remission, but which of the two scoring systems is better remains controversial.

METHODS

Patient data from 463 obese East Asian patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or SG with duodenojejunal bypass (SG-DJB) as a primary operation and were followed for at least 3 years were retrospectively collected from 24 institutions. The correlation between the ABCD and IMS scoring systems and the discrimination power of the models was evaluated. The cut-off point for the IMS stage of T2DM severity was also revised to adjust the scoring system to obese East Asian patients.

RESULTS

The two scoring systems were significantly well correlated. The IMS scoring system showed significant differences in T2DM remission rates between the procedures in the moderate stage, but the ABCD score showed no significant differences in each category. The discrimination power of the IMS score was comparable to that of the ABCD score at both 3 and 5 years. The revised IMS scoring system showed that SG-DJB had significantly higher T2DM remission rates in the moderate stage at 5 years than RYGB or SG.

CONCLUSION

IMS score may be comparable to ABCD score to predict T2DM remission in obese East Asian patients. The revised IMS scoring system may also select candidates for SG or SG-DJB.

Impact of metabolic surgery on 10-year cardiovascular disease risk in Chinese individuals with type 2 diabetes

BACKGROUND

In recent years, many reports have highlighted that metabolic surgery may ameliorate the cardiovascular risk in morbidly obese patients with or without type 2 diabetes (T2D). However, few studies have evaluated the long-term cardiovascular disease (CVD) risk after metabolic surgery in T2D patients with a low body mass index (BMI).

OBJECTIVES

To use the Prediction for ASCVD Risk in China (China-PAR) equations and United Kingdom Prospective Diabetes Study (UKPDS) risk engine to assess the 10-year CVD risk in low-BMI T2D patients after metabolic surgery.

SETTING

University hospital, China.

METHODS

We retrospectively reviewed our prospectively collected data of T2D patients who underwent metabolic surgery at our hospital between 2010 and 2018. We included patients who met the criteria for calculating a 10-year cardiovascular risk score by the China-PAR equations and UKPDS risk engine. Demographic characteristics, anthropometric variables, and glycolipid metabolic parameters were assessed preoperatively and during a 4-year follow-up period. Patients with a BMI < 30 kg/m² were compared with those with a BMI > 30 kg/m².

RESULTS

We evaluated 117 patients, of whom 62 (53%) had a BMI < 30 kg/m² and 55 (47%) had a BMI > 30 kg/m². Patients with a BMI < 30 kg/m² were significantly older and had a longer duration of diabetes. The rate of complete T2D remission in the group of patients with BMIs < 30 kg/m² was significantly lower than that in the group with BMIs > 30 kg/m² (35.2% versus 56.1%, respectively; P = .042). The overall 10-year and lifetime atherosclerotic cardiovascular disease risks were reduced from 4.2% to 2.3% and 25.3% to 13.9%, respectively (both P < .05), at 1 year postoperatively using the China-PAR equation. The overall 10-year coronary heart disease (CHD) and fatal CHD risks were reduced by 48.1% and 53.1%, respectively, at 1 year after surgery using the UKPDS risk engine. The advantages of metabolic surgery in reducing CVD risks are similar in both BMI groups, whether using the China-PAR equation or the UKPDS risk engine.

CONCLUSION

The 10-year CVD risk in T2D patients with BMIs < 30 kg/m² and BMIs > 30 kg/m² were significantly reduced after metabolic surgery, although the rate of complete T2D remission T2Din patients with BMIs < 30 kg/m² was lower than that in patients with BMIs > 30 kg/m². The China-PAR equation is a reliable and useful clinical tool for CVD risk evaluation in Chinese patients after metabolic surgery.

Validating Risk Prediction Models of Diabetes Remission After Sleeve Gastrectomy

INTRODUCTION

Many risk prediction models of diabetes remission after bariatric and metabolic surgery have been proposed. Most models have been created using Roux-en-Y gastric bypass cohorts. However, validation of these models in sleeve gastrectomy (SG) is limited. The objective of our study is to validate the performance of risk prediction models of diabetes remission in obese patients with diabetes who underwent SG.

METHOD

This retrospective cohort study included 128 patients who underwent SG with at least 1 year follow-up from Dec 2011 to Sep 2016 as the validation cohort. A literature review revealed total 11 models with 2 categories (scoring system and logistic regression), which were validated by our study dataset. Discrimination was evaluated by area under the receiver operating characteristic (AUC) while calibration by Hosmer-Lemeshow test and predicted versus observed remission ratio.

RESULTS

At 1 year after surgery, 71.9% diabetes remission (HbA1c < 6.0 off medication) and 61.4% excess weight loss were observed. Individual metabolic surgery, ABCD, DiaRem, Advanced-DiaRem, DiaBetter, Ana et al., and Dixon et al. models showed excellent discrimination power (AUC > 0.8). In calibration, all models overestimated diabetes remission from 5 to 30% but did not lose their goodness of fit.

CONCLUSION

This is the first comprehensive external validation of current risk prediction models of diabetes remission at 1 year after SG. Seven models showed excellent predicting power, and scoring models were recommended more because of their easy utility.

Does Metabolic Surgery Lead to Diabetes Remission in Patients with BMI < 30 kg/m2?: a Meta-analysis

BACKGROUND

Bariatric surgery has demonstrated to be effective in remission of type 2 diabetes in obese patients, but it is unclear in non-obese patients. The aim of this study is to investigate if metabolic surgery is effective in diabetes resolution in patients with BMI < 30 kg/m².

MATERIALS AND METHODS

A systematic review was performed and the content of the PubMed, Ovid, and the Cochrane Library databases covering the period January 2008 to April 2018 was searched. Studies with metabolic surgery performed in patients with type 2 diabetes, BMI < 30 kg/m² and a follow-up ≥ 6 months were included. Type 2 diabetes remission rate and metabolic parameters changes were measured. A meta-analysis was conducted with the selected studies.

RESULTS

Twenty-six studies were included in the meta-analysis (1105 patients). The mixed-effects meta-analysis model for overall diabetes remission rate produced an estimate of 43% (95% IC 34-53%, p < 0.001). Moderator effects of the variables race, preoperative HbA1c, BMI, months of follow-up, duration of diabetes, and age on diabetes remission were also assessed, with no significant effects being found in any of them. A reduction in BMI (- 3.57 kg/m²), fasting blood glucose (- 55.93 mg/dL) and HbA1c (- 2.08%) was observed after surgery.

CONCLUSIONS

Metabolic surgery could be effective in remission of type 2 diabetes in BMI < 30 kg/m² patients but randomized and long-term studies are necessary. The scientific community should agree in a single definition of type 2 diabetes remission, in order to know the real effect of metabolic surgery in this group of patients.

Selection of Bypass vs Sleeve for the Management of Type-2 Diabetes in Severely Obese: Could Ethnicity Play a Role?

PURPOSE

Prospective data was evaluated to see whether bariatric procedure type made any difference to diabetes remission.

METHODS

One hundred eighty-six consecutive patients of Indian ethnicity (M:F 89:97) with type 2 diabetes mellitus (T2DM) and HbA1c > 6.5 were assessed before and at 1 year following surgery. Age, BMI, C-peptide and duration of diabetes (ABCD - described by WJ Lee), insulin use, baseline HbA1c, and % weight loss were tested as modifiers. We present remission rates (HbA1c ≤ 6.0%) and between group remission odds ratio (OR) and adjusted OR after controlling for key modifiers.

RESULTS

Patients selecting RYGB (n = 113) vs SG (n = 73) were older (50.7 vs 44.2 years), had a lower BMI (44.1 vs 46.7), lower C-peptide (3.5 vs 4.7 ng/ml), greater duration of diabetes (8 vs 3 years), and higher HbA1c (8.90 and 7.9%) respectively p < 0.05 for all (combined R² = 0.38). Weight loss at 1 year was 27 and 30% for RYGB and SG respectively (p = 0.01). Remission at 1 year was achieved by 37% of patient selecting RYGB and 74% for the SG (OR = 0.21, 95% CI 0.11-0.41, p < 0.001). After adjusting for ABCD, the adjusted OR (AOR) still favored the SG (AOR = 0.32, 0.14-0.74, p = 0.01), and adjustment for HbA1c and weight loss (AOR 0.4, 0.17-0.95, p = 0.038) attenuated the effect.

CONCLUSION

The analysis suggests SG may be superior to RYGB in this Indian population. Ethnicity may play a role in predicting the response to bariatric surgery and hence the choice of procedure. A randomized controlled trial is needed to clarify the relative benefit.

Ethnicity Does Not Influence Glycemic Outcomes or Diabetes Remission After Sleeve Gastrectomy or Gastric Bypass in a Multiethnic Asian Cohort

BACKGROUND

In Asia, metabolic-bariatric surgery (MBS) rates have grown rapidly in parallel with rising prevalence of obesity and type 2 diabetes (T2D).

OBJECTIVE

The objective of this study was to identify factors that influence glycemic outcomes and diabetes remission 12 months after sleeve gastrectomy (SG) or gastric bypass (GB) in a multiethnic Asian cohort.

SETTING

The study's setting was in a tertiary hospital in Singapore.

METHODS

Data from 145 T2D patients who had SG (37%) or GB (63%) and at least 1-year follow-up were analyzed. Diabetes remission was defined as hemoglobin A1c ≤ 6.0% without diabetes medications. Analysis involved binary logistic regression to identify predictors and general linear regression for variables associated with glycemic improvement after surgery.

RESULTS

Baseline parameters are as follows: BMI 40.0 ± 7.6 kg/m², A1c 8.4 ± 1.6%, diabetes duration 9.3 years, ethnic composition: Chinese (51.7%), Malay (23.4%), Indian (20.7%), Others (4.1%). 55.9% achieved diabetes remission at 1 year. Baseline A1c, baseline BMI, and diabetes duration were significant pre-operative factors for remission (cumulative R ² = 0.334). At 12 months, percentage weight loss was similar after SG (24.1 ± 7.4%) and GB (25.4 ± 7.4%, p = 0.31). Greater A1c decrease was seen with GB compared to SG (2.7 ± 1.6 vs 2.0 ± 1.5%, p = 0.006), significant even after adjustment for weight loss, age, BMI, baseline A1c, and diabetes duration (p = 0.033). Weight loss at 12 months also correlated independently with A1c reduction. Ethnicity did not influence weight loss, diabetes remission, or glycemic control after MBS.

CONCLUSION

Baseline A1c, baseline BMI, and diabetes duration independently predict diabetes remission after MBS. GB is more effective in controlling T2D compared to SG despite similar weight loss, whereas ethnicity does not play a significant role in the multiethnic Asian cohort.

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

BACKGROUND

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

OBJECTIVES

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

SETTING

Hospital das Clínicas, Federal University of Pernambuco, Brazil.

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT OF WEIGHT LOSS TRAJECTORY FOLLOWING RANDOMIZATION TO BARIATRIC SURGERY ON LONG-TERM DIABETES GLYCEMIC AND CARDIOMETABOLIC PARAMETERS

Objective: It is unclear whether acute weight loss or the chronic trajectory of weight loss after bariatric surgery is associated with long-term type 2 diabetes mellitus (T2DM) glycemic improvement. This ancillary study of the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial aimed to answer this question. Methods: In STAMPEDE, 150 patients with T2DM were randomized to bariatric surgery, and 96 had 5-year follow-up. Data post-Roux-en-Y gastric bypass (RYGB, n = 49) and sleeve gastrectomy (SG, n = 47) were analyzed. We defined percent weight loss in the first year as negative percent decrease from baseline weight to lowest weight in the first year. Percent weight regain was positive percent change from lowest weight in the first year to fifth year. Weight change was then correlated with cardiometabolic (CM) and glycemic outcomes at 5 years using Spearman rank correlations and multivariate analysis. Results: In both RYGB and SG, less weight loss in the first year positively correlated with higher 5-year glycated hemoglobin (HbA1c) (RYGB, β = +0.13; P<.001 and SG, β = 0.14; P<.001). In SG, greater weight regain from nadir positively correlated with higher HbA1c (β = 0.06; P = .02), but not in RYGB. Reduced first-year weight loss was also correlated with increased 5-year triglycerides (β = 1.81; P = .01), but not systolic blood pressure. Weight regain did not correlate with CM outcomes. Conclusion: Acute weight loss may be more important for T2DM glycemic control following both RYGB and SG as compared with weight regain. Clinicians should aim to assist patients with achieving maximal weight loss in the first year post-op to maximize long-term health of patients. Abbreviations: BMI = body mass index; HbA1c = glycated hemoglobin; RYGB = Roux-en-Y gastric bypass; SBP = systolic blood pressure; SG = sleeve gastrectomy; STAMPEDE = Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently; T2DM = type 2 diabetes mellitus; TG = triglyceride.

Role of Bile Acids and GLP-1 in Mediating the Metabolic Improvements of Bariatric Surgery

BACKGROUND & AIMS

Bile diversion to the ileum (GB-IL) has strikingly similar metabolic and satiating effects to Roux-en-Y gastric bypass (RYGB) in rodent obesity models. The metabolic benefits of these procedures are thought to be mediated by increased bile acids, although parallel changes in body weight and other confounding variables limit this interpretation.

METHODS

Global G protein-coupled bile acid receptor-1 null (Tgr5^-/-) and intestinal-specific farnesoid X receptor null (Fxr^Δ/E) mice on high-fat diet as well as wild-type C57BL/6 and glucagon-like polypeptide 1 receptor deficient (Glp-1r^-/-) mice on chow diet were characterized following GB-IL.

RESULTS

GB-IL induced weight loss and improved oral glucose tolerance in Tgr5^-/-, but not Fxr^Δ/E mice fed a high-fat diet, suggesting a role for intestinal Fxr. GB-IL in wild-type, chow-fed mice prompted weight-independent improvements in glycemia and glucose tolerance secondary to augmented insulin responsiveness. Improvements were concomitant with increased levels of lymphatic GLP-1 in the fasted state and increased levels of intestinal Akkermansia muciniphila. Improvements in fasting glycemia after GB-IL were mitigated with exendin-9, a GLP-1 receptor antagonist, or cholestyramine, a bile acid sequestrant. The glucoregulatory effects of GB-IL were lost in whole-body Glp-1r^-/- mice.

CONCLUSIONS

Bile diversion to the ileum improves glucose homeostasis via an intestinal Fxr-Glp-1 axis. Altered intestinal bile acid availability, independent of weight loss, and intestinal Akkermansia muciniphila appear to mediate the metabolic changes observed after bariatric surgery and might be manipulated for treatment of obesity and diabetes.

Prediction of Type 2 Diabetes Remission after Bariatric or Metabolic Surgery

Bariatric surgery has evolved from a surgical measure for treating morbid obesity to an epochal remedy for treating metabolic syndrome as a whole, which is represented by type 2 diabetes mellitus. Numerous clinical trials have advocated bariatric or metabolic surgery over nonsurgical interventions because of markedly superior metabolic outcomes in morbidly obese patients who satisfy traditional criteria for bariatric surgery (body mass index [BMI] >35 kg/m2) and in less obese or simply overweight patients. Nevertheless, not all diabetes patients achieve the most desirable outcomes; i.e., diabetes remission after metabolic surgery. Thus, candidates for metabolic surgery should be carefully selected based on comprehensive preoperative assessments of the risk-benefit ratio. Predictors for diabetes remission after metabolic surgery may be classified into two groups based on mechanism of action. The first is indices for preserved pancreatic beta-cell function, including younger age, shorter duration of diabetes, and higher C-peptide level. The second is the potential for an insulin resistance reduction, including higher baseline BMI and visceral fat area. Several prediction models for diabetes remission have been suggested by merging these two to guide the joint decision-making process between clinicians and patients. Three such models, DiaRem, ABCD, and individualized metabolic surgery scores, provide an intuitive scoring system and have been validated in an independent external cohort and can be utilized in routine clinical practice. These prediction models need further validation in various ethnicities to ensure universal applicability.

Diabetes Intervention Accentuating Diet and Enhancing Metabolism (DIADEM-I): a randomised controlled trial to examine the impact of an intensive lifestyle intervention consisting of a low-energy diet and physical activity on body weight and metabolism in early type 2 diabetes mellitus: study protocol for a randomized controlled trial

Background

Type 2 diabetes mellitus (T2DM) and obesity are syndemic and will have a significant impact on affected individuals and healthcare services worldwide. Evidence shows that T2DM remission can be achieved with significant weight loss in those who are younger with early diabetes and requiring fewer medications for glycaemic control. DIADEM-I aims to examine the impact of an intensive lifestyle intervention (ILI) using a low-energy diet (LED) meal replacement approach combined with physical activity in younger individuals with early T2DM.

Methods

The planned study is an ongoing, non-blinded, pragmatic, randomised controlled, parallel-group trial examining the impact of an LED-based ILI on body weight and diabetes remission in younger (18–50 years) T2DM individuals with early diabetes (≤ 3-year duration). The ILI will be compared to usual medical care (UMC). The primary outcome will be weight loss at 12 months. Other key outcomes of interest include diabetes remission, glycaemic control, diabetes complications, cardiovascular health, physical activity, mental health, and quality of life. It is planned for the study to include 138 subjects for assessment of the primary outcome. Safety will be assessed throughout.

Discussion

If DIADEM-I demonstrates a clinically significant effect for younger individuals with early T2DM, it will inform clinical guidelines and services of the future for management of T2DM.

Trial registration

ISRCTN: ISRCTN20754766 (date assigned: 7 June 2017); ClinicalTrials.gov, ID: NCT03225339 Registered on 26 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2660-1) contains supplementary material, which is available to authorized users.

Effects of Laparoscopic Roux-en-Y Gastric Bypass for Type 2 Diabetes Mellitus: Comparison of BMI > 30 and < 30 kg/m2

Background

Recently, many studies focused on type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) < 30 kg/m² and suggested that those patients might benefit from Roux-en-Y gastric bypass (RYGB). However, evidence on its effectiveness to improve T2DM patients with BMI < 30 kg/m² is still lacking. The aim of this study is to explore whether T2DM patients with BMI < 30 kg/m² get similar surgical effect from RYGB compared with those patients with BMI > 30 kg/m².

Methodology

Seventy patients with uncontrolled T2DM underwent laparoscopic RYGB from May 2010 to December 2015 in the GI Department of Daping Hospital. Weight, BMI, waist circumference, glucose, and lipid metabolic parameters were collected and evaluated at baseline and 1, 3, 6, 12, and 24 months postsurgery. Patients with BMI < 30 kg/m² were compared with those with BMI > 30 kg/m².

Results

Among the 70 patients, 47 (67.1%) BMI < 30 kg/m², and 23 (32.9%) BMI > 30 kg/m². Patients with BMI < 30 kg/m² are significantly older; they are female predominant and have longer duration of diabetes. The complete remission of T2DM was 28.2% of the BMI < 30 kg/m² group and 57.9% of the BMI > 30 kg/m² group (p = 0.029). There was no significant difference in the change of glucose and lipid metabolic parameters of both groups. FPG, 2hPG, and HbA1c% levels were significantly improved after 1 month (p < 0.05), and then remained essentially stable from the sixth month in both groups.

Conclusions

The 2-year study has shown that RYGB is a safe and effective procedure in treating T2DM with BMI < 30 kg/m², although the complete remission of T2DM in the BMI < 30 kg/m² group is lower than the BMI > 30 kg/m² group.

DIABETES REMISSION RATE IN DIFFERENT BMI GRADES FOLLOWING ROUX-EN-Y GASTRIC BYPASS

Background:

Type 2 diabetes mellitus has a high long-term remission rate after laparoscopic Roux-en-Y gastric bypass (LRYGB), but few studies have analyzed patients with BMI<35 kg/m².

Aim:

To compare glycemic control after LRYGB between BMI 30-35 kg/m² (intervention group or IG) and >35 kg/m² patients (control group or CG) and to evaluate weight loss, comorbidities and surgical morbidity.

Methods:

Sixty-six diabetic patients (30 in IG group and 36 in CG group) were submitted to LRYGB. Data collected annually after surgery were analyzed with generalized estimating equations.

Results:

Average follow-up was 4.3 years. There was no statistical difference between groups using complete remission American Diabetes Association criteria (OR 2.214, 95%CI 0.800-5.637, p=0.13). There was significant difference between groups using partial remission American Diabetes Association criteria (p=0.002), favouring the CG group (OR 6.392, 95%CI 1.922-21.260). The higher BMI group also had lower HbA1c levels (-0.77%, 95%CI -1.26 to -0.29, p=0.002). There were no significant differences in remission of hypertension, dyslipidemia and surgical morbidity, while weight was better controlled in the IG group.

Conclusion:

No differences were found in diabetes complete remission, although greater partial remission and the lower levels of glycated hemoglobin in the BMI >35 kg/m² group suggest a better response among more obese diabetic patients with LRYGB. In addition, both groups had important metabolic modifications at the expense of low morbidity.

The effect of metabolic surgery on nonobese patients (BMI<30 kg/m2) with type 2 diabetes: a systematic review

BACKGROUND

The influence of metabolic surgery on the glucose and lipid profiles of nonobese body mass index<30 kg/m² patients with type 2 diabetes, particularly the effect ≥1 year, remains unknown.

METHODS

PubMed and Ovid Embase were used.

SETTING

University hospitals.

RESULTS

In total, 21 studies including 921 patients were examined in this systematic review, the results of which revealed decrease in body mass index, waist circumference, fasting plasma glucose, glycosylated hemoglobin A1C, fasting C-peptide, fasting insulin, homeostasis model of assessment for insulin resistance index, triglycerides, total cholesterol, and low-density lipoprotein cholesterol. An increase in high-density lipoprotein cholesterol was also observed. The diabetes remission rates ranged from 13.3% to 90.2% according to 20 studies. The incidence of gastrointestinal bleeding ranged from 1% to 10% according to 9 studies. Four studies reported anemia after Roux-en-Y gastric bypass or one-anastomosis gastric bypass, with the incidence ranging from 8% to 33%.

CONCLUSIONS

Nonobese patients can achieve improvements in weight-related indices and glucose and lipid profiles in the short and medium term after metabolic surgery; however, the complications of metabolic surgery warrant further attention.

Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass for Type 2 Diabetes Mellitus

BACKGROUND

Laparoscopic sleeve gastrectomy with duodenojejunal bypass (LSG-DJB), which has been positioned as a novel bariatric procedure, is the combination of vertical sleeve gastrectomy and proximal intestinal bypass and is theoretically expected to have strong anti-diabetic effect. Also, preserving the pylorus, a physiological valve, leads to less occurrence of dumping syndrome and anastomotic stenosis which are often problematic after laparoscopic Roux-en-Y gastric bypass (LRYGB), a gold standard. The purpose of this study was to investigate the clinical effects of LSG-DJB on obese patients with type 2 diabetes mellitus (T2DM).

METHODS

Consecutive 75 obese patients (female 44/male 31) associated with T2DM who underwent LSG-DJB and were followed up for at least 1 year were analyzed. The mean age was 45.5 ± 8.6 years, and the mean preoperative body weight (BW) and body mass index (BMI) were 108.4 ± 21.4 kg and 39.6 ± 7.3 kg/m(2), respectively. The mean hemoglobin A1c (HbA1c) at the first visit was 9.0 ± 1.9 %, and the duration of T2DM from diagnosis was 7.2 ± 6.2 years. Thirty-six out of the 75 patients (48 %) were treated with insulin preoperatively. All patients were evaluated and managed under a strict multidisciplinary team approach. The follow-up rate at 1 year was 89 %.

RESULTS

At 1 year, the mean BW and BMI significantly dropped to 74.6 ± 16.9 kg and 27.5 ± 5.7 kg/m(2), respectively. The mean percent of excess weight loss (%EWL) and percent of total body weight loss (%TWL) were 99.4 ± 42.4 and 31.6 ± 8.8 %, respectively. Consequently, 68.7 % of the patients achieved HbA1c less than 6 %, and 82.1 % of them achieved HbA1c less than 6.5 % without diabetes medications. Glycemic control of HbA1c less than 7 % was achieved in 91.0 % of the patients. The percentage of patients who satisfied the American Diabetes Association (ADA)-defined composite endpoints for cardiovascular disease (CVD) risk factor control increased from 0 % (at baseline) to 31 % (at 1 year). A meal tolerance test revealed significant reduction of glucose area under the curve (AUC) and increase of insulin AUC postoperatively.

CONCLUSIONS

LSG-DJB for obese patients with T2DM has strong anti-diabetic effect in the short-term; however, a larger number of patients with a longer follow-up period are needed for definitive conclusions.

Metabolic Surgery in Korea: What to Consider before Surgery

Obesity is increasing globally and represents a significant global health problem because it predisposes towards various diseases, such as type 2 diabetes mellitus, cardiovascular disease, degenerative joint disease, and certain types of cancer. Numerous studies have shown that bariatric surgery reduces body mass and ameliorates obesity-related complications, such as hypertension and hyperglycemia, suggesting that surgery is the most effective therapeutic option for severely obese and obese diabetic patients. Recent international guidelines recommend surgical treatment for diabetic patients with class III obesity (body mass index [BMI] >40 kg/m²), regardless of their level of glycemic control or the complexity of their glucose-lowering regimens, and for patients with class II obesity (BMI 35.0 to 39.9 kg/m²) and hyperglycemia that is poorly controlled despite appropriate lifestyle and pharmacological therapy. The most popular procedures are Roux-en-Y gastric bypass and sleeve gastrectomy, but new procedures with better outcomes have been reported. For optimal surgical outcome, comprehensive management including assessments of a medical condition, nutrition, mental health, and social support is needed before and after surgery. However, there is still a lack of understanding regarding metabolic surgery in Korea. Therefore, this article reviews indications for metabolic surgery in patients with a specific focus on the situation in Korea.

[Efficacy of two bariatric surgeries in type 2 diabetic patients with a body mass index of 25-27.5]

OBJECTIVE

To evaluate the therapeutic effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic duodenal-jejunal bypass with sleeve gastrectomy (SADJB-SG) in patients with type 2 diabetes mellitus and a low body mass index (BMI) of 25-27.5.

METHODS

Thirty-one type 2 diabetic patients with a BMI of 25-27.5 underwent bariatric surgeries in the General Hospital of Guangzhou Military Command between August, 2013 and August, 2015. The patients receiving LRYGB (17 cases) and SADJB-SG (14 cases) were compared for physical indexes, glucose metabolism and of pancreatic islet function at 1 year after the surgeries.

RESULTS

No mortality occurred in the patients after the operations. At 1 year after the operation, the patients in LRYGB group showed significant improvements in body weight, BMI, glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), oral glucose tolerance test 2 h (OGTT2h), C-peptide, fasting insulin (FINS), and postprandial 2 hour insulin (2 hPINS) (P<0.05); in SADJB-SG group, significant improvements were observed in the body weigh, BMI, HbA1c, FPG, OGTT2h, and FINS after the operation (P<0.05). The postoperative improvements in body weigh, BMI, HbA1c, FPG, OGTT2h, C-peptide, and 2hPINS were comparable between SADJB-SG group and LRYGB group (P>0.05), but the incidence of postoperative anastomotic ulcer was lower in SADJB-SG group.

CONCLUSION

SADJB-SG and LRYGB produce similar therapeutic effects in type 2 diabetic patients with a low BMI, but SADJB-SG is associated with a low incidence of postoperative complications and is therefore more suitable in such patients.

Metabolic Surgery for Type 2 Diabetes Mellitus: Experience from Asia

Type 2 diabetes mellitus (T2DM) is a current global health priority and Asia is the epicenter of this epidemic disease. Unlike in the west, where older population is most affected, the burden of diabetes in Asian countries is disproportionately high in young to middle-age adults. The incidence of diabetic nephropathy is alarmingly high in patients with early onset T2DM, especially in those with poor glycemic control. How to control this chronic and debilitating disease is currently a very important health issue in Asia. Bariatric surgery has proven successful in treating not just obesity but also T2DM in morbid obese patients (body mass index [BMI] >35 kg/m²). Gastrointestinal metabolic surgery recently has been proposed as a new treatment modality for obesity related T2DM for patients with BMI <35 kg/m². Many studies from Asia reported promising results of metabolic surgery to treat obese patients with T2DM which is not well controlled. It has been demonstrated that changes in gastrointestinal hormone secretion after gastrointestinal surgery would favor an early improvement of T2DM in Asians. New procedures have also been designed and proposed specifically for the treatment of diabetes in Asia. This article examines clinical trial data and accepted algorithms with a view toward elucidating the application of metabolic surgery for the treatment of T2DM in the Asia. We propose a systematic approach to surgical treatment, addressing current evidences, patient selection, procedure of choice, and timing and guideline for new procedures.

Systematic review of risk prediction models for diabetes after bariatric surgery

BACKGROUND

Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery.

METHODS

A systematic literature review was performed in MEDLINE, MEDLINE-In-Process, Embase and the Cochrane Central Register of Controlled Trials databases in April 2015. All English-language full-text published derivation and validation studies for risk prediction models on diabetic outcomes after bariatric surgery were included. Data extraction included population, outcomes, variables, intervention, model discrimination and calibration.

RESULTS

Of 2330 studies retrieved, eight met the inclusion criteria. Of these, six presented development of risk prediction models and two reported validation of existing models. All included models were developed to predict diabetes remission. Internal validation using tenfold validation was reported for one model. Two models (ABCD score and DiaRem score) had external validation using independent patient cohorts with diabetes remission assessed at 12 and 14 months respectively. Of the 11 cohorts included in the eight studies, calibration was not reported in any cohort, and discrimination was reported in two.

CONCLUSION

A variety of models are available for predicting risk of diabetes following bariatric surgery, but only two have undergone external validation.

Can low BMI Chinese patients with type 2 diabetes benefit from laparoscopic Roux-en-Y gastric bypass surgery?

BACKGROUND

The efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) in type 2 diabetes mellitus (T2D) is closely associated with the preoperative body mass index (BMI) of the patient. There is a lack of long-term and large sampling evidence on the efficacy of LRYGB in T2D patients with low BMI in China.

OBJECTIVES

This retrospective study aimed to evaluate the efficacy of surgical treatment in a Chinese population with T2D (especially patients with BMI<27.5 kg/m²).

SETTING

University-affiliated hospital, China METHODS: Seventy-eight patients with T2D were included in the study and evaluated before and after LRYGB surgery. No patients were lost to follow-up at any time points.

RESULTS

Thirty-eight T2D patients with BMI≥27.5 kg/m² in group 1 (high BMI group) had significant improvements in waist circumference, blood glucose levels, homeostasis model assessment-insulin resistance index, and C-peptide levels after LRYGB (P<.05). Forty T2D patients with BMI<27.5 kg/m² in group 2 (low BMI group, including 19 T2D patients with BMI<25 kg/m²) had significant improvements in waist circumference and waist-to-hip ratio after LRYGB (P< .05).

CONCLUSIONS

LRYGB surgery may be beneficial in T2D patients with BMI<27.5 kg/m² in China.

Preoperative Predictive Factors of Successful Weight Loss and Glycaemic Control 1 Year After Gastric Bypass for Morbid Obesity

BACKGROUND

Gastric bypass (GBP) is one of the most effective surgical procedures to treat morbid obesity and the related comorbidities. This study aimed at identifying preoperative predictors of successful weight loss and type 2 diabetes mellitus (T2DM) remission 1 year after GBP.

METHODS

Prospective longitudinal study of 771 patients who underwent GBP was performed at four Italian centres between November 2011 and May 2013 with 1-year follow-up. Preoperative anthropometric, metabolic and social parameters, the surgical technique and the previous failed bariatric procedures were analyzed. Weight, the body mass index (BMI), the percentage of excess weight lost (% EWL), the percentage of excess BMI lost (% BMIL) and glycated haemoglobin (HbA1c) were recorded at follow-up.

RESULTS

Univariate and multivariate analysis showed that BMI <50 kg/m(2) (p = 0.006) and dyslipidaemia (p = 0.05) were predictive factors of successful weight loss. Multivariate analysis of surgical technique showed significant weight loss in patients with a small gastric pouch (p < 0.001); the lengths of alimentary and biliary loops showed no statistical significance. All diabetic patients had a significant reduction of HbA1c (p < 0.001) after surgery. BMI ≥ 50 kg/m(2) (p = 0.02) and low level of preoperative HbA1c (p < 0.01) were independent risk factors of T2DM remission after surgery.

CONCLUSIONS

This study provides a useful tool for making more accurate predictions of best results in terms of weight loss and metabolic improvement.

The Effect and Predictive Score of Gastric Bypass and Sleeve Gastrectomy on Type 2 Diabetes Mellitus Patients with BMI < 30 kg/m(2)

BACKGROUND

Metabolic surgery is a novel therapy for mild obesity (BMI 30-35 Kg/m(2)) in type 2 diabetes mellitus (T2DM) patients. The ABCD score, which comprise age, BMI, C-peptide level, and duration of T2DM (years), was reported as useful in predicting the success of T2DM treatment using metabolic surgery. This study examines gastric bypass and sleeve gastrectomy as a salvage treatment for non-obese (BMI < 30 kg/m(2)) T2DM patients and evaluates the role of ABCD scores.

METHODS

From January 2007 to July 2013, 512 (71.2%) of 711 T2DM patients enrolled in a metabolic surgical program had at least 1-year follow-up were recruited. Clinical data and outcomes of 80 (15.6%) patients with BMI < 30 Kg/m(2) were compared with those of the other 432 (84.4%) patients with BMI ≥ 30 Kg/m(2). Complete remission was defined as HbA1c ≤ 6%, and partial remission was defined as HbA1c < 6.5%. A binary logistic regression was used to identify predictors of T2DM remission.

RESULTS

Mean age of the 80 non-obese T2DM patients was 47.7 ± 9.1 years, and mean HbA1c and disease duration were 9.1 ± 1.8% and 6.5 ± 5.1 years, respectively. Mean total body weight loss was 17.1 ± 7.4% at 1 year, and mean BMI decreased from 26.9 ± 2.2 to 22.7 ± 2.5 kg/m(2) at 1 year. Complete remission of T2DM was achieved in 25.0% of patients, and partial remission was achieved in 23.8%. The complete remission rate was significantly lower than the 49.5% found in patients with BMI 30-35 and 79.0% of patients with BMI > 35 Kg/m(2). In univariate analysis, non-obese patients who had T2DM remission after surgery were heavier and had a wider waist, higher C-peptide levels, shorter disease duration, more weight loss, and higher ABCD score than those without remission. The ABCD score remained the only independent predictor of success after multivariate logistical regression analyses (P = 0.003).

CONCLUSIONS

Metabolic surgery may be useful in achieving glycemic control of selected non-obese T2DM patients. The ABCD score is a simple multidimensional grading system that can predict the success of T2DM treatment.

Determinants of Diabetes Remission and Glycemic Control After Bariatric Surgery

OBJECTIVE

Eligibility criteria for bariatric surgery in diabetes include BMI ≥35 kg/m(2) and poorly controlled glycemia. However, BMI does not predict diabetes remission, and thus, predictors need to be identified.

RESEARCH DESIGN AND METHODS

Seven hundred twenty-seven patients were included in a database merged from the Swedish Obese Subjects (SOS) study and two randomized controlled studies, with 415 surgical and 312 medical patients in total. Bariatric operations were divided into gastric only (GO) and gastric plus diversion (GD).

RESULTS

Sixty-four percent of patients in the surgical arm and 15.0% in the medical arm experienced diabetes remission (P < 0.001). GO yielded 60% remission, and GD yielded 76% remission. The best predictors of diabetes remission were lower baseline glycemia and shorter diabetes duration. However, when operation type was considered, GD predicted a higher likelihood of remission and greater weight loss. Patients in remission (responders) lost more weight (25% vs. 17%) and waist circumference (18% vs. 13%) and experienced better insulin sensitivity than nonresponders.

CONCLUSIONS

Surgery is more effective than medical treatment in achieving diabetes remission and tighter glycemic control. Shorter diabetes duration, lower fasting glycemia before surgery, and GD versus GO procedures independently predict higher rates of remission, whereas baseline HbA1c and waist circumference predict improved glycemic control. The results show the advantage of an early operation together with better controlled glycemia on diabetes remission independently of BMI.

CLINICAL COURSE OF DIABETIC RETINOPATHY IN KOREAN TYPE 2 DIABETES AFTER BARIATRIC SURGERY: A Pilot Study

PURPOSE

To assess the changes in diabetic retinopathy (DR) in Type 2 diabetes (T2DM) patients after bariatric surgery.

METHODS

Consecutive 20 patients with T2DM who underwent bariatric surgery and were followed for at least 12 months were enrolled. The case history was reviewed retrospectively, and laboratory data were assessed at baseline and every 3 months postoperatively. Two retinal specialists evaluated the severity of DR with dilated fundus examination preoperatively and postoperatively. Factors associated with DR progression were assessed.

RESULTS

During the follow-up period, 2 of 12 patients without DR and 2 of 3 patients with mild nonproliferative DR before surgery developed moderate nonproliferative DR. All five patients with moderate nonproliferative DR or worse preoperatively had progression requiring intervention. Preexisting DR (P = 0.005) and albuminuria (P = 0.01) were identified as associated with DR progression. Six patients (30%) entered remission of T2DM, but remission of T2DM could not halt the DR progression.

CONCLUSION

Diabetic retinopathy progression can occur in patients with or without before DR after bariatric surgery, regardless of remission of T2DM. All patients with T2DM should be examined regularly by an ophthalmologist postoperatively, and more carefully patients with previous DR or albuminuria.

Correlation between postoperative weight loss and diabetes mellitus remission: a meta-analysis

OBJECTIVE

This meta-analysis was conducted to determine the effect of percent excess weight loss (%EWL) after bariatric surgery on diabetes remission.

METHODS

The Cochrane Library, PubMed, MEDLINE, Embase, and CINAHL were searched. All reports on %EWL involving humans and published in English between 1 January 1992 and 1 September 2013 were included in the analysis.

RESULTS

Eight studies involving 1,247 patients who underwent bariatric surgery were selected. %EWL was positively associated with remission rate (WMD = 11.15, 95 % CI: 6.73-15.56, p < 0.01) in the Caucasian population.

CONCLUSIONS

Patients with extensive weight loss were more likely to achieve T2DM remission after bariatric surgery. Further randomized controlled trials (RCTs) with uniform remission criterion should be performed to provide more reliable evidence.

Malabsorption as a Therapeutic Approach in Bariatric Surgery

Background

The increasing prevalence of obese patients will lead to a more frequent use of bariatric procedures in the future. Compared to conservative medical therapy, bariatric procedures achieve greater weight loss and superior control of comorbidities, resulting in improved overall mortality.

Methods

A search for current literature regarding mechanisms, indications, and outcomes of bariatric surgery was performed.

Results

In order to care for patients after bariatric surgery properly, it is important to understand its mechanisms of action and effects on gastrointestinal physiology. Recent investigations indicate that the beneficial effects of bariatric procedures are much more complex than simply limiting food intake or an associated malabsorption. Changes in gastrointestinal hormone secretion, energy expenditure, intestinal bacterial colonization, bile acid metabolism, and epigenetic modifications resulting in altered gene expression are likely responsible for the majority of the beneficial effects of bariatric surgery. Malabsorptive bariatric procedures divert the flow of bile and pancreatic enzymes from food and therefore limit the digestion and absorption of nutrients, resulting in reduced calorie intake and subsequent weight loss. Essential micronutrients such as vitamins and trace elements are also absorbed to a lesser extent, potentially leading to severe side effects.

Conclusion

To prevent malnutrition, dietary supplementation and regular control of micronutrient levels are mandatory for patients undergoing malabsorptive bariatric procedures, in whom the fat-soluble vitamins A and D are commonly deficient.

Single-anastomosis gastric bypass (SAGB): appraisal of clinical evidence

Single-anastomosis (mini-) gastric bypass (SAGB) was proposed by Dr. Robert Rutledge. Criticism and prejudice against this procedure was raised by surgeons who preferred a more difficult procedure, laparoscopic Roux-en-Y gastric bypass (RYGB). Increasing data indicates the procedure is an effective and durable bariatric procedure. SAGB has lower operation risks compared to RYGB. The weight loss is better after SAGB because of a greater malabsorptive component than RYGB, but SAGB had a higher incidence of micronutrient deficiencies. Randomized controlled trial and long-term data demonstrate that SAGB can be regarded as a simpler and safer alternative to RYGB. We propose this procedure to be renamed "single-anastomosis gastric bypass (SAGB)" because the key feature of SAGB is the "single anastomosis" compared with the two anastomoses of RYGB.

Bariatric Surgery for Type 2 Diabetes Mellitus in Patients with BMI <30 kg/m2: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

The role of bariatric surgery in non-obese patients with type 2 diabetes (T2DM) remains unclear, and its use in clinical practice is controversial. We conducted a systemic review and meta-analysis to investigate the metabolic changes after surgical treatment in diabetic patients with body mass index (BMI) <30 kg/m2.

METHODS

We conducted a comprehensive search in MEDLINE (PubMed), EMBASE and the Cochrane Library of published articles from January 2000 to April 2013 reporting the clinical outcome changes in various metabolic outcomes in diabetic patients with BMI <30 kg/m2.

RESULTS

Ten prospective studies including 290 patients were included in the meta-analysis. Bariatric surgery led to an overall 2.79 kg/m2 [95%CI 2.05~3.53, P<0.00001] reduction in BMI, a 1.88%[95%CI 1.32~2.43, P<0.00001] reduction in glycosylated hemoglobin, a 3.70 mmol/L [95%CI, 1.93~5.47, P<0.00001] reduction in fasting blood glucose, a 6.69 mmol/L [95%CI, 2.29~11.08, P=0.003] reduction in postprandial glucose, anda 3.37 [95%CI 0.55~6.18, P=0.02] reduction in homeostasis model assessment of insulin resistance (HOMA-IR). After surgical treatment, 76.2% of the patients were insulin free, and 61.8% patients were off medication. In total, 90(42.4%), 10(37%) and 34(37.2%) patients had post-surgical HbA1c levels of <6%,<6.5% and<7%, respectively. No deaths were observed in the included studies, and the major complication rate was 6.2%.

CONCLUSIONS

Based on the currently available data, bariatric surgery might improve glycemic control and weight loss in a very limited range with a doubled surgical complication rate in drug-refractory T2DM patients with BMI <30 kg/m2. It remains too premature to suggest bariatric surgery for non-obese T2DM patients.

Predictors of long-term diabetes remission after metabolic surgery

BACKGROUND DATA

Bariatric/metabolic surgery has been proposed for the treatment of inadequately controlled type 2 diabetes mellitus (T2DM) in obese patients. However, prediction on successful long-term remission of T2DM after metabolic surgery has not been clearly studied. Our objectives were to evaluate rates of long-term remission of T2DM after metabolic surgery and determine the independent predictors of remission.

METHODS

Outcomes of 157 patients who underwent metabolic surgery between 2006 and 2009 and who had complete 5-year follow-up data were assessed. Prolonged complete remission was defined as glycated hemoglobin (HbA1c) less than 6 % without diabetes medication up to 5 years. Predictors of prolonged remission studies included patient characteristics such as glucose level, HbA1c, body weight, waist circumference, blood pressure, total cholesterol, LDL, triglyceride, uric acid, AST, alanine transaminase (ALT), albumin, insulin, C-peptide, iron, calcium, complete blood cell count, the ABCD score (a multidimensional grading system composed of age, body mass index (BMI), C-peptide levels, and duration of T2DM), and postoperative weight loss.

RESULTS

At 5 years after surgery, the weight loss was 27.1 % and the mean BMI decreased from 39.8 to 28.8 kg/m(2). The mean HbA1c decreased from 8.3 to 6.0 %. A significant number of patients had improvement in their glycemic control, including 97 (71.3 %) patients who had complete remission (HbA1c < 6.0 %), 27 (19.9 %) partial remission (HbA1c < 6.5 %), and 12 (8.8 %) improved condition (HbA1c < 7 %). In univariate analysis, patients with prolonged T2DM remission after surgery were younger and heavier; had a wider waist, higher C-peptide, shorter duration of T2DM, higher liver enzyme, higher insulin resistance, higher C-peptide level, and higher white blood cell count; were taking smaller insulin dosage; had higher ABCD score; and had greater weight loss than those without remission. Multivariate logistical regression analyses showed that the ABCD score and weight loss were the only predictors of remission after metabolic surgery.

CONCLUSIONS

Metabolic surgery is a treatment option for patients with obesity and T2DM. Baseline ABCD score and weight loss have a major influence on outcome.

Recent advances in bariatric/metabolic surgery: appraisal of clinical evidence

Obesity and associated type 2 diabetes mellitus (T2DM) are becoming a serious medical issue worldwide. Bariatric surgery has been shown to be the most effective and durable therapy for the treatment of morbid obese patients. Increasing data indicates bariatric surgery as metabolic surgery is an effective and novel therapy for not well controlled obese T2DM patients. The review of recent developments in bariatric/metabolic surgery covers 4 major fields. 1) Improvement of safety: recent advances in laparoscopic/metabolic surgery has made this minimal invasive surgery more than ten times safer than a decade ago. The safety profile of laparoscopic/metabolic surgery is compatible with that of laparoscopic cholecystectomy now. 2) New bariatric/metabolic surgery: laparoscopic sleeve gastrectomy (LSG) is becoming the leading bariatric surgery because of its simplicity and efficacy. Other new procedures, such as gastric plication, banded plication, single anastomosis (mini) gastric bypass and Duodeno-jejunal bypass with sleeve gastrectomy have all been accepted as treatment modalities for bariatric/metabolic surgery. 3) Mechanism of bariatric/metabolic surgery: Restriction is the most important mechanism for bariatric surgery. Weight regain after bariatric surgery is usually associated with loss of restriction. Recent studies demonstrated that gut hormone, microbiota and bile acid changes after bariatric surgery may play an important role in durable weight loss as well as in T2DM remission. However, weight loss is still the cornerstone of T2DM remission after metabolic surgery. 4) PATIENT SELECTION: patients who may benefit most from bariatric surgery was found to be patients with insulin resistance. For Asian T2DM patients, the indication of metabolic surgery has been set to those with not well controlled (HbA1c > 7.5%) disease and with their BMI > 27.5 Kg/m(2). A novel diabetes surgical score, ABCD score, is a simple system for predicting the success of surgical therapy for T2DM.

Metabolic bariatric surgery and type 2 diabetes mellitus: an endocrinologist's perspective

Traditional treatment of T2DM consisting of modification of diet, an exercise regimen, and pharmacotherapy has problems of poor lifestyle modifications and fail tend of treatment over time, now bariatric surgery is recommended for treatment of obese patients with T2DM because its great improvements on weight loss and metabolic. In this article, effects of bariatric surgery on diabetes and diabetes-related complications are reviewed.

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.