Current status of bariatric surgery in the treatment of type 2 diabetes

Dynamics of adipose tissue macrophage populations after gastric bypass surgery

OBJECTIVE

This case-control study aimed to analyze the dynamics of macrophage infiltration in subcutaneous adipose tissue following bariatric surgery or conservative treatment of obesity and to clarify whether these features predict the weight loss outcome after the surgery.

METHODS

Subcutaneous tissue samples taken before and 12 months after laparoscopic Roux-en-Y gastric bypass surgery (n = 39) or conservative (n = 43) treatment for obesity were analyzed. Fat cell size was determined, and with CD68 immunohistochemistry, crown-like structures (CLS) were counted and single macrophages were quantitated.

RESULTS

A major decline in CLS density from 4.1 (SD 3.5) to 1.1 (SD 0.8) per 1000 fat cells (p < 0.000) was found, regardless of the degree of weight loss after the surgery. Surgery had no effect on the fraction of infiltrating single-cell macrophages in subcutaneous adipose tissue. The abundance of these macrophage populations before the intervention did not predict the degree of postsurgery weight loss or suboptimal response to the surgery.

CONCLUSIONS

The effect of gastric bypass on adipose tissue inflammatory status associates closely with CLS density even in subjects with suboptimal weight loss. The study suggests that factors related to bypass surgery other than weight loss modify the inflammatory response in adipose tissue.

Length of stay by uncomplicated diabetes bariatric surgery patients: A laparoscopic adjustable banding versus laparoscopic sleeve gastrectomy

RATIONALE, AIMS, AND OBJECTIVE

Bariatric surgery is an effective procedure for morbidly obese patients when all else fails. The purpose of this study was to compare the hospital length of stay (LOS) for two surgical procedures, laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG).

METHODS

This study was a retrospective cross-sectional analysis of the Nationwide Inpatient Sample (NIS) from 2009 to 2014. Patients who received bariatric surgery as indicated by International Classification of Diseases, Ninth Revision (ICD-9) procedure codes were selected (N = 4001). Cases were limited to uncomplicated diabetic patients. Differences in the odds of long vs short (2< and ≥2) stay for a patient receiving LSG were compared with LAGB while adjusting for hospital volume, hospital size, patient age, gender, ethnicity, season, and year using logistic regression analysis.

RESULTS

The odds for LSG (odds ratio [OR] = 0.100, 0.066-0.150, P < 0.001) patients for long LOS are lower when compared with LAGB. In the stratified logistic regression model, both male (OR = 0.157, 0.074-0.333, P < 0.001) and female (OR = 0.077, 0.046-0.127, P < 0.001) had reduced odds of extended LOS for LSG. Discharged patients in the year 2012 (OR = 0.660, 0.536-0.813, P < 0.001) had decreased odds of having a longer LOS when compared with the year 2014. Both government, nonfederal (OR = 0.452, 0.251-0.816, P = 0.008), and private investor-owned (OR = 0.421, 0.244-0.726, P < 0.001) patients had similar odds for long duration of stay when compared with government or private. Urban non-teaching (OR = 1.954, 1.653-2.310, P < 0.001) patients had higher odds for long LOS in comparison with urban teaching. New England patients' (OR = 0.365, 0.232-0.576, P < 0.001) odds for extended LOS were lower when compared with pacific. Both patients who received care in low (OR = 1.330, 1.109-1.595, P = 0.002) and medium (OR = 1.639, 1.130-2.377, P = 0.009) volume hospital had increased odds for long duration of stay. Female patients in the stratified logistic regression model with high (OR = 1.330, 1.109-1.595, P < 0.002) volume had elevated odds of extended LOS when compared with very low volume hospital.

CONCLUSION

Among the uncomplicated diabetic patients, LSG provides a substantially low odds of extended LOS after adjusting for covariates when compared with LAGB. The finding of the relative reduction in LOS for LSG suggests opportunities for improvement both for cost reduction for third party insurance payers and greater efficacy and outcomes for patients.

Impact of Fecal Microbiota Transplantation on Obesity and Metabolic Syndrome-A Systematic Review

Fecal microbiota transplantation (FMT) is a gut microbial-modulation strategy that has been investigated for the treatment of a variety of human diseases, including obesity-associated metabolic disorders. This study appraises current literature and provides an overview of the effectiveness and limitations of FMT as a potential therapeutic strategy for obesity and metabolic syndrome (MS). Five electronic databases and two gray literature sources were searched up to 10 December 2018. All interventional and observational studies that contained information on the relevant population (adult patients with obesity and MS), intervention (receiving allogeneic FMT) and outcomes (metabolic parameters) were eligible. From 1096 unique citations, three randomized placebo-controlled studies (76 patients with obesity and MS, body mass index = 34.8 ± 4.1 kg/m², fasting plasma glucose = 5.8 ± 0.7 mmol/L) were included for review. Studies reported mixed results with regards to improvement in metabolic parameters. Two studies reported improved peripheral insulin sensitivity (rate of glucose disappearance, RD) at 6 weeks in patients receiving donor FMT versus patients receiving the placebo control. In addition, one study observed lower HbA1c levels in FMT patients at 6 weeks. No differences in fasting plasma glucose, hepatic insulin sensitivity, body mass index (BMI), or cholesterol markers were observed between two groups across all included studies. While promising, the influence of FMT on long-term clinical endpoints needs to be further explored. Future studies are also required to better understand the mechanisms through which changes in gut microbial ecology and engraftment of microbiota affect metabolic outcomes for patients with obesity and MS. In addition, further research is needed to better define the optimal fecal microbial preparation, dosing, and method of delivery.

Review: When should bariatric surgery be used in the treatment of type 2 diabetes?

Non-randomised observational studies show that bariatric surgery has a highly beneficial impact on diabetes. Bariatric surgery leads to remission of bariatric surgery has a highly beneficial impact on Diabetes. Bariatric surgery leads to remission of diabetes in at least two thirds of patients, and reductions in drug therapy for many others. Those with more recent onset diabetes, fewer treatment requirements, and able to achieve most weight loss are more likely to achieve remission. Therefore, bariatric surgery is an attractive treatment option to consider for selected more severely obese patients with favourable characteristics. Although data on bariatric surgery in subjects with diabetes are provocative, all recent clinical studies have been uncontrolled or otherwise flawed. Moreover, bariatric surgery has yet to be compared either with medical treatment for weight loss, or against standard medical treatment for diabetes in any randomised controlled trial with diabetes-specific end points. There remains a need for long-term randomised controlled trials before bariatric surgery is used more widely as a first-line treatment for obese patients with type 2 diabetes.

Evaluation of Weight Loss Failure, Medical Outcomes, and Personal Experiences after Roux-en-Y Gastric Bypass: A Critical Analysis

Background. Roux-en-Y gastric bypass (RYGB) is considered an effective and well-tolerated surgical procedure. In this retrospective study, we critically assessed efficacy and negative personal experiences (NPEs) after RYGB with a self-administered questionnaire (SAQ). Methods. This questionnaire study included 404 patients who had undergone RYGB. Analysis was performed using data from medical records, referral letters, and SAQs at an average of 33 months after procedure. We evaluated the occurrence of hypertension, CPEP use and type 2 diabetes mellitus (T2DM), the amount of excess weight loss, degree of satisfaction and negative personal experiences (NPEs) related to the procedure, and adherence to a dedicated life style program and (non)attendance to followup. consults after surgery. Results. 42.3% of all SAQs were evaluable for analysis. T2DM remained similar, while hypertension and continuous positive airway pressure (CPAP) use decreased significantly; excess weight loss of ≥40% was reported in 69% and of <40% in 19%, a significant improvement. Absolute weight gain was reported in 10.5%, fatigue in 44.4%, dysphagia in 11.6%, and other NPEs in 7.6%. Dissatisfaction over weight loss was reported in 9.4%. Mean number of follow-up visits was 9.6 per respondent, while nonattendance of any follow-up visit consults occurred in 1.8%. Conclusions. The use of post-RYGB SAQs provided evaluable data in 42.3%. Treatment failure after RYGB appears to be relevant, encouraging the use of SAQ studies in large cohorts.

Biliopancreatic diversion with duodenojejunal exclusion associated with truncal vagotomy: a new proposal for type 2 diabetes mellitus treatment

PURPOSE

To evaluate the effectiveness of the biliopancreatic diversion surgery with duodenojejunal exclusion in combination with truncal vagotomy in type 2 diabetes mellitus (T2DM) patients with overweight or class I or II obesity.

METHODS

The study included ten patients with T2DM and class I or II obesity or overweight who were subjected to biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy. The blood glucose levels during the pre- and postoperative periods were compared using the Friedman test. The significance level adopted was 5%.

RESULTS

There were significant differences between preoperative and postoperative blood glucose levels at three months (p=0.01), six months (p=0.001) and 12 months (p=0.001). There was also a significant difference between one month postoperative blood glucose and six months postoperative blood glucose (p=0.01). Glycosylated hemoglobin levels decreased in 80% of patients, there was marked improvement in their lipid profiles, and the average BMI reduction was 7.0±1.5 kg/m² at 12 months after the surgery.

CONCLUSION

In patients with type 2 diabetes mellitus associated with class I/II obesity or overweight, performing biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy resulted in glycemic control, reduction of excess weight, and improvement of lipid profile 12 months after the surgery.

Diabetes-specific nutrition algorithm: a transcultural program to optimize diabetes and prediabetes care

Type 2 diabetes (T2D) and prediabetes have a major global impact through high disease prevalence, significant downstream pathophysiologic effects, and enormous financial liabilities. To mitigate this disease burden, interventions of proven effectiveness must be used. Evidence shows that nutrition therapy improves glycemic control and reduces the risks of diabetes and its complications. Accordingly, diabetes-specific nutrition therapy should be incorporated into comprehensive patient management programs. Evidence-based recommendations for healthy lifestyles that include healthy eating can be found in clinical practice guidelines (CPGs) from professional medical organizations. To enable broad implementation of these guidelines, recommendations must be reconstructed to account for cultural differences in lifestyle, food availability, and genetic factors. To begin, published CPGs and relevant medical literature were reviewed and evidence ratings applied according to established protocols for guidelines. From this information, an algorithm for the nutritional management of people with T2D and prediabetes was created. Subsequently, algorithm nodes were populated with transcultural attributes to guide decisions. The resultant transcultural diabetes-specific nutrition algorithm (tDNA) was simplified and optimized for global implementation and validation according to current standards for CPG development and cultural adaptation. Thus, the tDNA is a tool to facilitate the delivery of nutrition therapy to patients with T2D and prediabetes in a variety of cultures and geographic locations. It is anticipated that this novel approach can reduce the burden of diabetes, improve quality of life, and save lives. The specific Southeast Asian and Asian Indian tDNA versions can be found in companion articles in this issue of Current Diabetes Reports.

Impact of laparoscopic adjustable gastric banding on type 2 diabetes

Bariatric surgery is becoming an accepted option for obese people with type 2 diabetes. Our aim was to assess the impact of laparoscopic adjustable gastric banding (LAGB) through a systematic review of the literature. Data was sourced from Scopus, MEDLINE and EMBASE published from 2000 through May 2011, and five unpublished studies that were performed by industry for regulatory approval were also included. Studies were selected on the basis that they provide some detail of diabetes status before and after LAGB. There were 35 studies meeting the inclusion criteria. There was considerable heterogeneity in study design, sample size, length of follow-up, attrition rates and classification of diabetes status. Weight loss was progressive over the first 2 years with a weighted average of 47% excess weight loss at 2 years. Remission or improvement in diabetes varied from 53% to 70% over different time periods. Results were broadly consistent, demonstrating clinically relevant improvements in diabetes outcomes with sustained weight loss in obese people with type 2 diabetes following LAGB surgery. However, there were significant shortcomings in the reviewed literature with few high-quality studies, inconsistent reporting of diabetes outcomes and high attrition rates. Long-term studies that address these limitations are needed.

Surgical approaches to the treatment of obesity: bariatric surgery

As the obesity epidemic continues to grow in the Unites States, so does the search for the ideal nonsurgical or surgical solution. Bariatric surgery continues to be the most sustainable form of weight loss available to morbidly obese patients. In addition, bariatric surgery has established an acceptable safety profile with respect to morbidity and mortality. With the number of elective bariatric cases growing in recent years, it is unsurprising that results have improved and better data are emerging regarding improvement of obesity-related comorbid conditions. Additionally, ample evidence suggests that bariatric surgery may increase longevity, particularly through reducing cardiovascular deaths. Although the specific mechanisms involved in the remission of these medical conditions remain to be fully elucidated, it has become clear that bariatric surgery has established a significant and firm role in the treatment of medical comorbidities that result directly from obesity. However, until commercial insurance carriers provide improved coverage for bariatric surgery, patient access to these treatments will remain limited.

Bariatric surgery in patients with type 2 diabetes: a viable option

The prevalence of obesity is increasing and is co-epidemic with type 2 diabetes mellitus (T2DM). Treatment of obesity has been less than adequate, particularly when managing morbidly obese patients. Research on T2DM has shown a number of new pharmacologic therapies along with the rapid employment of bariatric surgery. Improvement of T2DM, including its remission, after bariatric surgery has been recognized for more than a decade. However, not all procedures are the same. Restrictive procedures, malabsorptive procedures, or a combination of both procedures have their own categorical risks and benefits. Which procedure to choose has to do with many patient selection factors, notwithstanding insurance coverage. Based on operative and postoperative mortality data, laparoscopically assisted gastric bypass (LAGB) has been shown to be the safest bariatric surgery procedure. However, the Roux-en-Y gastric bypass procedure is one of the most widely used for obese patients with T2DM. The mechanisms involved in weight loss and improved blood glucose control appear to involve increased insulin sensitivity, decreased lipotoxicity/inflammation, and changes in gut hormones/incretins. The safety of bariatric procedures has improved; complication rates are low and mortality is < 1% for all procedures. As a result of the dramatic, positive impact of bariatric procedures on T2DM in obese patients, physicians should be cautious during patient selection to avoid performing the procedure on patients who are overzealous about reported outcomes, but who are not candidates for the procedure. Other data gaps still exist regarding diabetes surgery, which must be filled using data from well-designed, well-implemented randomized controlled clinical trials. In the future, it will be prudent to compare surgical interventions with other rigorous medical interventions in more robust studies. A combination of surgical, medical, and behavioral interventions should be considered for treating obese patients with T2DM.

Bariatric surgery for diabetes: gastric banding is simple and safe

Bariatric surgery (BS) is an important treatment option for selected patients with obesity and type 2 diabetes, and laparoscopic adjustable gastric banding (LAGB) is an effective procedure for many of these patients. This treatment has become preferred in many centres because it is the simplest current option and therefore has substantially better short- and long-term safety profiles than the alternative and more invasive surgical procedures that are advocated by some. The selection of suitable patients for this and other forms of BS, optimum outcomes and follow-up of these patients requires more active involvement of diabetes teams. LAGB is a safe and effective treatment for type 2 diabetes, but just as with pharmacological therapies — diabetes teams should take more ownership of the initial decision to employ BS and acquire the skills and knowledge to ensure that patients obtain full metabolic benefit from this treatment.

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

Obesity plays a key role in the pathophysiology of type 2 diabetes (T2DM), and weight loss is a major objective, although difficult to achieve with medical treatments. Bariatric surgery has proven its efficacy in obtaining marked and sustained weight loss, and is also associated with a significant improvement in glucose control and even diabetes remission. Roux-en-Y gastric bypass appears to be more effective in diabetic patients than the restrictive gastroplasty procedure. This may be explained not only by greater weight reduction, but also by specific hormonal changes. Indeed, increased levels of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) may lead to improved beta-cell function and insulin secretion as well as reduced insulin resistance associated with weight loss. The presence of T2DM in obese individuals is a further argument to propose bariatric surgery, and even more so when diabetes is difficult to manage by medical means and other weight-related complications may occur. Bariatric surgery is associated with a better cardiovascular prognosis and reduced mortality, even though acute and long-term complications are present. The observation that surgical rerouting of nutrients triggers changes in the release of incretin hormones that, in turn, ameliorate the diabetic state in the absence of weight loss has led to the recent development of innovative surgical procedures. Thus, bariatric surgery may be said to be progressing towards so-called 'metabolic surgery', which merits further evaluation in patients with T2DM within a multidisciplinary approach that involves both surgeons and endocrinologists.

Surgical approaches to the treatment of obesity: bariatric surgery

As bariatric surgery for the treatment of morbid obesity enters its sixth decade, much has been and continues to be learned from the results of several key bariatric operations, particularly the Roux-en-Y gastric bypass. Because of the obesity epidemic and development of the laparoscopic approach, bariatric procedures have increased exponentially in the past decade and are now among the more commonly performed gastrointestinal operations. Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. The mechanisms involved in the remission of these conditions, however, remain poorly understood and constitute an exciting area of research. This article delineates the current types of bariatric surgery, their respective outcomes, and their impact on obesity-related medical comorbidities.

Remission of Diabetes after Laparoscopic Gastric Bypass

Diabetes is a well-recognized and treatable risk factor for cardiac disease, and one of many comorbidities associated with obesity. The aim of this study was to evaluate the clinical outcome of a cohort of morbidly obese patients with documented diabetes who underwent laparoscopic Roux-en-Y gastric bypass. Fifty-nine patients with sufficient follow-up were included in the study. Mean preoperative duration of diabetes was 68 months. At 1 month postoperatively, mean excess body weight loss was 17 per cent with 29 patients (49%) showing improvement and 21 patients (36%) having remission of their disease. Mean excess body weight loss was 67 per cent at 12 months postoperatively with 25 patients (42%) showing improvement and 34 patients (58%) having remission of diabetes. Mean preoperative fasting blood glucose level decreased from 152 g/dL preoperatively to 100 g/dL at 12 months (P = 0.02), whereas glycosylated hemoglobin decreased from 7.9 per cent to 5.7 per cent, respectively (P < 0.01). Patients with remission of diabetes had a shorter length of condition compared with patients with only improvement (43 vs 103 months, P < 0.01). Weight loss associated with laparoscopic gastric bypass significantly improves diabetes control and results in discontinuation or marked reduction of antidiabetic medications in the majority of patients. Improvement in glucose control occurs as early as 1 month postoperatively.

Papel da cirurgia bariátrica no controle do diabete melito tipo II

RACIONAL: Sabe-se que hoje um dos grandes problemas de saúde pública refere-se a diabete melito com projeção de atingir 366 milhões de pacientes até 2030, entre indivíduos insulino (DM tipo I) e não-insulino (DM tipo II) dependentes. OBJETIVOS: Avaliar por meio de revisão ampla da literatura os resultados encontrados no controle do DM tipo II com diferentes modalidades de tratamento cirúrgico disponíveis em nosso meio. MÉTODO: A partir de 2004 foram levantados 73 trabalhos, sendo que destes 22 versavam especificamente sobre o tema nas bases de dados LiIacs, Medline, Pubmed cruzando os descritores diabete melito e cirurgia. RESULTADOS: Dentre as operações avaliadas obtiveram resultados satisfatórios em 98,9% a derivação biliopancreática ou duodenal, em 83,7% bypass gástrico, em 71,6% gastroplastia e em 47,9% bandas gástricas. Quanto às complicações, encontram-se descritas as mais diversas, desde as da ferida operatória até casos de insuficiência hepática aguda após cirurgia bariátrica que evoluíram com necessidade de transplante ou mesmo óbito, demonstrando que a decisão pelo tratamento operatório deve ser feita de maneira criteriosa ponderando-se o custo benefício. CONCLUSÃO: As técnicas cirúrgicas bariátricas, exercem melhora do diabete tipo II e as derivações biliopancreática, duodenal switch, Scopinaro e bypass gástrico com Y de Roux são as mais indicadas.

Laparoscopic treatment of type 2 diabetes mellitus for patients with a body mass index less than 35

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a common disease with numerous complications. Bariatric surgery is an efficient procedure for controlling T2DM in morbidly obese patients. In T2DM, the incretin effect is either greatly impaired or absent. This study aimed to evaluate the preliminary results from interposing a segment of ileum into the proximal jejunum associated with a sleeve or diverted sleeve gastrectomy to control T2DM in patients with a body mass index (BMI) less than 35 kg/m(2).

METHODS

For this study, 39 patients (16 women and 23 men) underwent two laparoscopic procedures comprising different combinations of ileal interposition into the proximal jejunum via a sleeve or diverted sleeve gastrectomy. The mean age of these patients was 50.3 years (range, 36-66 years). The mean BMI was 30.1 kg/m(2) (range, 23.4-34.9 kg/m(2)). All the patients had a diagnosis of T2DM that had persisted for at least 3 years and evidence of stable treatment with oral hypoglycemic agents or insulin for at least 12 months. The mean duration of T2DM was 9.3 years (range, 3-22 years).

RESULTS

The mean operative time was 185 min, and the median hospital stay was 4.3 days. Four major complications occurred in the short term (30-days), and the mortality rate was 2.6%. The mean postoperative follow-up period was 7 months (range, 4-16 months), and the mean percentage of weight loss was 22%. The mean postoperative BMI was 24.9 kg/m(2) (range, 18.9-31.7 kg/m(2)). An adequate glycemic control was achieved for 86.9% of the patients, and 13.1% had important improvement. The patients whose glycemia was not normalized were using a single oral hypoglycemic agent. No patient needed insulin therapy postoperatively. All the patients except experienced normalization of their cholesterol levels. Targeted triglycerides levels were achieved by 71% of the patients, and hypertension was controlled for 95.8%.

CONCLUSIONS

The laparoscopic ileal interposition via either a sleeve gastrectomy or diverted sleeve gastrectomy seems to be a promising procedure for the control of T2DM and the metabolic syndrome. A longer follow-up period is needed.

Prediabetes: a must to recognise disease state

Prediabetes mellitus (PDM) is defined as a state of abnormal glucose homeostasis in which deficiency or resistance to insulin is the hallmark. PDM precedes the development of overt type 2 DM. It is associated with increased mortality and morbidity and thus fits well with the criteria of a disease condition. Framing PDM as a disease and not a risk or a 'pre' stage for diabetes is needed to facilitate early management.

AIM

This review aims therefore to increase awareness of PDM as a disease state.

METHODS

To do so, we shall preview guidelines for its diagnosis. Its prevalence and hazards will be then discussed. Finally, we shall elaborate on the current treatment guidelines.

RESULT

Enough evidence support the notion that PDM is a curable disease state.

CONCLUSIONS

The current recommendations for the treatment of PDM should be adhered. In addition, there is a room for the use of other pharmacological agents.

Weight loss before gastric bypass: feasibility and effect on postoperative weight loss and weight loss maintenance

BACKGROUND

This study was performed at a tertiary care university hospital. We hypothesized that weight loss before laparoscopic Roux-en-Y gastric bypass (LRYGB) is feasible, does not diminish the expected postoperative weight loss, and might enhance overall weight loss and maintenance.

METHODS

A population of 351 consecutive patients, who had undergone LRYGB, was divided into 4 groups depending on the percentage of body weight loss achieved before surgery (group 1, none or gain; group 2, <5%; group 3, 5-10%; and group 4, >10%). Data were collected regarding the demographics, body mass index (BMI) change, and excess weight loss and analyzed by analysis of variance and Fisher's exact test at the alpha = 0.05 level.

RESULTS

All groups were demographically similar in age and were predominantly women. The maximal follow-up was 36 months. Groups 3 and 4 had significantly greater initial excess weight and BMI (P <.05) but these became similar after the preoperative weight loss. Most patients (74%) were able to lose weight before surgery, with 36% losing >5% body weight. Preoperative weight loss did not decrease the magnitude of the expected postoperative weight loss. Patients who lost weight preoperatively demonstrated more excess weight loss and BMI change (from their initial weight) that was sustained far into the postoperative period and reached statistical significance at several points (P <.05).

CONCLUSION

The results of this study have demonstrated that obese patients are capable of losing weight before LRYGB and that this weight loss does not negatively affect their expected postoperative weight loss. Furthermore, preoperative weight loss combined with LRYGB might result in better long-term excess weight loss and BMI change than surgery alone.

Metabolic aspects of bariatric surgery

Insulin resistance is a nearly universal finding in morbid obesity. It may be compensated and latent or uncompensated with single or multiple clinical abnormalities. Although lifestyle interventions and medical measures alone may control most metabolic problems in the short term, the ultimate benefits of such an approach are usually limited by the complexity of available therapeutic regimens and the difficulty of maintaining full patient compliance. Many studies now document that bariatric surgery can effectively and safely control these complications in the short term and long term or even prevent their occurrence. Further investigations are needed to understand better the mechanisms involved and to define more clearly the appropriate indications and contraindications of the treatments proposed.

Pregnancy outcome of patients with gestational diabetes mellitus following bariatric surgery

OBJECTIVE

The objective of the study was to investigate pregnancy outcome of patients with gestational diabetes mellitus following bariatric surgery.

STUDY DESIGN

All births to patients with gestational diabetes mellitus delivered between the years 1988 and 2002 were included in the study. A comparison between patients with and without a history of bariatric surgery was performed. Stratified analyses, using the Mantel-Haenszel technique and a multiple logistic regression model were performed to control for confounders.

RESULTS

During the study period, there were 8014 deliveries of women with gestational diabetes mellitus. Twenty-eight were in patients following bariatric surgery. Most patients underwent restrictive (n = 26) and not malabsorptive procedures (n = 2), mainly gastric banding (n = 16). Mean levels of hemoglobin A1c and fasting glucose were comparable between the groups. No significant differences in obstetric characteristics or pregnancy outcomes were noted between the patients following bariatric surgery as compared with the comparison group, except for higher rates of fertility treatments (21.4% versus 5.5%; P < .001). While controlling for nulliparity and maternal age, using a multivariable analysis, a significant association was noted between bariatric surgery and fertility treatments (odds ratios 4.7; 95% confidence interval 1.9 to 11.7; P = .001). Perinatal outcome was comparable between the groups, and no significant differences were noted with regard to complications such as perinatal mortality, congenital malformations, and low Apgar scores at 1 and 5 minutes.

CONCLUSION

Previous bariatric surgery in patients with gestational diabetes mellitus is not associated with adverse perinatal outcome.

Assessment of obesity-related comorbidities: a novel scheme for evaluating bariatric surgical patients

BACKGROUND

Bariatric surgery serves as the superior means of achieving sustained weight loss and improvement in obesity-related comorbidities. Results of bariatric surgery have been reported qualitatively without standardized measurement of comorbidity response. The objective of this work was to develop a clinically based, standardized system for scaled assessment of the major comorbidities of obesity in patients undergoing bariatric surgery.

STUDY DESIGN

We constructed a standardized grading scheme for the major comorbidities of obesity, with each condition scored from 0 to 5, according to severity. Data were prospectively collected on 226 patients. Ninety patients have already undergone gastric bypass and are being followed at regular intervals postoperatively. Longest current followup interval is 1 year.

RESULTS

Preoperative evaluation of comorbidities identified a total of 1,356 medical disorders. Anatomic comorbidities were most prevalent as a category, although psychosocial impairment was the most common single condition. The majority of comorbidities in our patient population were graded mild (score of 1) to moderate (score of 3). Immediate (2 weeks) followup was available for all operated patients and ranged in number to 1 year postoperatively, depending on the date of operation. Statistically significant reduction in the severity of several comorbidities was observed at postoperative evaluation (p < 0.05).

CONCLUSIONS

This scheme for assessment of obesity-related comorbidities facilitates evaluation of bariatric surgical patients. The system allows standardized preoperative characterization of a bariatric patient population and uniform postoperative longitudinal assessment of changes in comorbidities after weight reduction operation.

Specific effects of biliopancreatic diversion on the major components of metabolic syndrome: a long-term follow-up study

OBJECTIVE

Gastric bypass and biliopancreatic diversion (BPD) are known to have a beneficial effect on glucose metabolism superior to that of the other bariatric operations. Thanks to its excellent weight loss results and to its specific actions, BPD has proven able to guarantee permanent normalization of serum glucose, triglyceride, and cholesterol levels in the vast majority, if not the totality, of operated patients. However, clinical studies on the duration of these effects in large patient populations are still lacking.

RESEARCH DESIGN AND METHODS

The files of 312 BPD obese patients with type 2 diabetes operated on from June 1984 to January 1993 were examined. Pre- and postoperative serum glucose, triglyceride, and cholesterol levels, along with arterial pressure measurements, were considered.

RESULTS

After BPD, fasting serum glucose concentration fell within normal values in all but two of the operated subjects and remained in the physiological range in all but six up until 10 years. Serum triglyceride and total cholesterol steadily normalized in all subjects with abnormally high preoperative values, and arterial hypertension disappeared in the vast majority of the preoperatively hypertensive patients.

CONCLUSIONS

BPD proved able to reverse all the major components of the metabolic syndrome in nearly all the operated subjects, with results being strictly maintained over a 10-year follow-up period. This outcome, which far exceeds those following similar weight loss at short or long term obtained by any other means, confirms the existence of specific actions of BPD on the major components of metabolic syndrome.

Reduction of macrophage infiltration and chemoattractant gene expression changes in white adipose tissue of morbidly obese subjects after surgery-induced weight loss

In human obesity, the stroma vascular fraction (SVF) of white adipose tissue (WAT) is enriched in macrophages. These cells may contribute to low-grade inflammation and to its metabolic complications. Little is known about the effect of weight loss on macrophages and genes involved in macrophage attraction. We examined subcutaneous WAT (scWAT) of 7 lean and 17 morbidly obese subjects before and 3 months after bypass surgery. Immunomorphological changes of the number of scWAT-infiltrating macrophages were evaluated, along with concomitant changes in expression of SVF-overexpressed genes. The number of scWAT-infiltrating macrophages before surgery was higher in obese than in lean subjects (HAM56+/CD68+; 22.6 +/- 4.3 vs. 1.4 +/- 0.6%, P < 0.001). Typical "crowns" of macrophages were observed around adipocytes. Drastic weight loss resulted in a significant decrease in macrophage number (-11.63 +/- 2.3%, P < 0.001), and remaining macrophages stained positive for the anti-inflammatory protein interleukin 10. Genes involved in macrophage attraction (monocyte chemotactic protein [MCP]-1, plasminogen activator urokinase receptor [PLAUR], and colony-stimulating factor [CSF]-3) and hypoxia (hypoxia-inducible factor-1alpha [HIF-1alpha]), expression of which increases in obesity and decreases after surgery, were predominantly expressed in the SVF. We show that improvement of the inflammatory profile after weight loss is related to a reduced number of macrophages in scWAT. MCP-1, PLAUR, CSF-3, and HIF-1alpha may play roles in the attraction of macrophages in scWAT.

Nutrient deficiencies secondary to bariatric surgery

PURPOSE OF REVIEW

The number of adolescent and adult patients submitting to bariatric surgery is increasing rapidly around the world. This review describes the literature published in the last few years concerning nutritional deficiencies after bariatric surgery as well as their etiology, incidence, treatment and prevention.

RECENT FINDINGS

Although bariatric surgery was first introduced in the 1950s, safe and successful surgical management has progressed over the last two decades and longer post-surgical follow-up data are now available. Most of the patients undergoing malabsorptive procedures will develop some nutritional deficiency, justifying mineral and multivitamin supplementation to all postoperatively. Nutrient deficiency is proportional to the length of absorptive area and to the percentage of weight loss. Low levels of iron, vitamin B12, vitamin D and calcium are predominant after Roux-en-Y gastric bypass. Protein and fat-soluble vitamin deficiencies are mainly detected after biliopancreatic diversion. Thiamine deficiency is common in patients with frequent vomiting. As the incidence of these deficiencies progresses with time, the patients should be monitored frequently and regularly to prevent malnutrition.

SUMMARY

Nutritional deficiencies can be prevented if a multidisciplinary team regularly assists the patient. Malnutrition is generally reverted with nutrient supplementation, once it is promptly diagnosed. Especial attention should be given to adolescents, mainly girls at reproductive age who have a substantial risk of developing iron deficiency. Future studies are necessary to detect nutrient abnormalities after new procedures and to evaluate the safety of bariatric surgery in younger obese patients.