Physiological and molecular responses to bariatric surgery: markers or mechanisms underlying T2DM resolution?

Optimal Small Bowel Limb Lengths of Roux-en-Y Gastric Bypass

PURPOSE OF REVIEW

Gastric bypass and biliopancreatic diversion (BPD) have come full circle, from a loop configuration to a Roux-en-Y and finally back to a loop configuration as one anastomosis gastric bypass and single-anastomosis duodenal switch. Most surgeons performing Roux-en-Y gastric bypass (RYGB) do not measure the common channel (CC) length and most surgeons performing BPD do not measure the biliopancreatic limb length (BPL).

RECENT FINDINGS

The small bowel length in humans is variable from as short as < 400 cm to as long as > 1000 cm. The combination of these two facts means that even if surgeons keep the limb lengths constant, surgeons will get variable limb length due to the variability of small bowel length in patients. Hence, outcomes of weight loss, resolution of medical problems, or developing nutritional deficiencies which are related to limb length are variable. In this article, we evaluate the published literature related to the effect of varying the Roux limb, BPL, CC, and total alimentary limb lengths on the outcomes of RYGB. We have focused on historical and current randomized controlled trials as well as systematic reviews and meta-analysis to outline the current literature and our interpretation of this literature.

Micronutrients in Pregnancy after Bariatric Surgery: A Narrative Review

Bariatric surgery is increasingly used in women of childbearing age due to the rising prevalence of obesity and the effectiveness and availability of this treatment. Pregnancy in women with previous bariatric surgery deserves special attention. Weight loss induced by surgery reduces the risks that obesity poses to pregnancy. But on the other hand, decreased intake and malabsorption may increase the risk of malnutrition and micronutrient deficiency and negatively affect maternal and foetal health. The aim of this narrative review is to provide an updated analysis of the impact of different bariatric surgery techniques on mineral and micronutrient nutritional status during pregnancy and the possible effect on maternal-foetal health.

Gut Factors Mediating the Physiological Impact of Bariatric Surgery

Despite decades of obesity research and various public health initiatives, obesity remains a major public health concern. Our most drastic but most effective treatment of obesity is bariatric surgery with weight loss and improvements in co-morbidities, including resolution of type 2 diabetes (T2D). However, the mechanisms by which surgery elicits metabolic benefits are still not well understood. One proposed mechanism is through signals generated by the intestine (nutrients, neuronal, and/or endocrine) that communicate nutrient status to the brain. In this review, we discuss the contributions of gut-brain communication to the physiological regulation of body weight and its impact on the success of bariatric surgery. Advancing our understanding of the mechanisms that drive bariatric surgery-induced metabolic benefits will ultimately lead to the identification of novel, less invasive strategies to treat obesity.

Effect of sleeve gastrectomy, Roux-en-Y gastric bypass, and ileal transposition on myocardial ischaemia-reperfusion injury in non-obese non-diabetic rats

Bariatric surgery (BS) improves outcomes in patients with myocardial infarction (MI). Here we tested the hypothesis that BS-mediated reduction in fatal MI could be attributed to its infarct-limiting effect. Wistar rats were randomized into five groups: control (CON), sham (SHAM), Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and ileotransposition (IT). Ten weeks later, animals were subjected to 30-min myocardial ischemia plus 120-min reperfusion. Infarct size (IS) and no-reflow area were determined histochemically. Fasting plasma levels of glucagon-like peptide-1 (GLP-1), leptin, ghrelin, and insulin were measured using ELISA. Compared with SHAM, RYGB and SG reduced IS by 22% (p = 0.011) and 10% (p = 0.027), and no-reflow by 38% (p = 0.01) and 32% (p = 0.004), respectively. IT failed to reduce IS and no-reflow. GLP-1 level was increased in the SG and RYGB groups compared with CON. In both the SG and RYGB, leptin level was decreased compared with CON and SHAM. In the SG group, ghrelin level was lower than that in the CON and SHAM. Insulin levels were not different between groups. In conclusion, RYGB and SG increased myocardial tolerance to ischemia-reperfusion injury of non-obese, non-diabetic rats, and their infarct-limiting effect is associated with decreased leptin and ghrelin levels and increased GLP-1 level.

Effects of three types of bariatric interventions on myocardial infarct size and vascular function in rats with type 2 diabetes mellitus

AIMS

The effects of three types of bariatric interventions on myocardial infarct size were tested in the rat model of type 2 diabetes mellitus (T2DM). We also evaluated the effects of bariatric surgery on no-reflow phenomenon and vascular dysfunction caused by T2DM.

MAIN METHODS

Rats with T2DM were assigned into groups: without surgery, sham-operated, ileal transposition, Roux-en-Y gastric bypass, and sleeve gastrectomy. Oral glucose tolerance, glucagon-like peptide-1, and insulin levels were measured. Six weeks after surgery, the animals were subjected to myocardial ischemia-reperfusion followed by histochemical determination of infarct size (IS), no-reflow zone, and blood stasis area size. Vascular dysfunction was characterized using wire myography.

KEY FINDINGS

All bariatric surgery types caused significant reductions in animal body weight and resulted in T2DM compensation. All bariatric interventions partially normalized glucagon-like peptide-1 responses attenuated by T2DM. IS was significantly smaller in animals with T2DM. Bariatric surgery provided no additional IS limitation compared with T2DM alone. Bariatric surgeries reversed T2DM-induced enhanced contractile responses of the mesenteric artery to 5-hydroxytryptamine. Sleeve gastrectomy normalized decreased nitric oxide synthase contribution to the endothelium-dependent vasodilatation in T2DM.

SIGNIFICANCE

T2DM resulted in a reduction of infarct size and no-reflow zone size. Bariatric surgery provided no additional infarct-limiting effect, but it normalized T2DM-induced augmented vascular contractility and reversed decreased contribution of nitric oxide to endothelium-dependent vasodilatation typical of T2DM. All taken together, we suggest that this type of surgery may have a beneficial effect on T2DM-induced cardiovascular diseases.

Roux-en-Y Gastric Bypass Surgery Has Early Differential Effects on Bile Acids and the Levels of Complement Component 3 and Acylation-Stimulating Protein

BACKGROUND

Bile acids have been implicated in the mechanism by which Roux-en-Y gastric bypass (RYGB) can induce remission of type 2 diabetes (T2D). Our goal was to identify circulating proteins whose levels changed after RYGB when dysglycemic parameters normalized.

MATERIALS AND METHODS

This was a retrospective study of 26 participants who underwent RYGB. Blood proteins were identified using two-dimensional electrophoresis and mass spectroscopy. Complement proteins were measured using immunoassays and bile acids measured using ultra-high-performance liquid chromatography and mass spectroscopy.

RESULTS

A total of 7/452 blood proteins were found to change 2 days after RYGB. Complement component 3 (C3) was selected because of its regulation by bile acids and the glucoregulatory function of its proteolytically processed product C3adesArg or acylation-stimulating protein (ASP). The median (inter-quartile range/IQR) C3 level was 47.4 (34.5, 65.9) mg/dL before surgery decreasing to 40.9 (13.4, 64.1) mg/dL within 2 days after surgery (p = 0.0292). The median (IQR) ASP level increased from 2.8 (0.9, 7.3) nM before surgery to 8.0 (5.3, 14.1) nM within 2 days after surgery (p = 0.0016). ASP levels increased in 14/17 (82%) with T2D remission and in 6/6 with normoglycemia but decreased in 3/3 with persistent T2D. Of ten bile acids measured, the levels of ursodeoxycholic acid (UDCA) were significantly decreased after RYGB and the levels of taurodeoxycholic acid (TDCA) were significantly decreased with T2D remission.

CONCLUSIONS

These data further support an association of C3 with glucose metabolism and implicate bile acids and ASP in the early remittive effects of RYGB on T2D.

Does Colectomy Improve Type 2 Diabetes?

Gastrectomy and gastric bypass improve type 2 diabetes (T2DM), potentially through alterations in intestinal hormones and the microbiome. The aim of this study was to analyze whether colorectal resections result in improvement of T2DM. A total of 171 patients with T2DM who underwent colectomy for benign diseases were studied with a median postoperative follow-up of 3 years (interquartile range [IQR] 1-5). The median BMI and glycated hemoglobin (HbA_1c) at baseline and post-colectomy were 30.3 kg/m² (IQR 26.6-34.6) versus 30.4 kg/m² (IQR 26.2-35) (p = 0.1), and 6.7% (IQR 6.2-7.5) versus 6.5% (IQR 6.5-7.1) (p = 0.5), respectively. The proportion of patients taking diabetes medications at baseline versus post-colectomy did not differ significantly. Changes in BMI, HbA_1c, and status of diabetes medications were not statistically different between the subtypes of colorectal resection. Our experience suggests that colectomy for benign colorectal diseases is not associated with long-term changes in body weight or glycemic control.

Plasma biomarkers of small intestine adaptations in obesity-related metabolic alterations

BACKGROUND

Evidence suggests that pathophysiological conditions such as obesity and type 2 diabetes (T2D) are associated with morphologic and metabolic alterations in the small intestinal mucosa. Exploring these alterations generally requires invasive methods, limiting data acquisition to subjects with enteropathies or undergoing bariatric surgery. We aimed to evaluate small intestine epithelial cell homeostasis in a cohort of men covering a wide range of adiposity and glucose homoeostasis statuses.

METHODS

Plasma levels of citrulline, a biomarker of enterocyte mass, and I-FABP, a biomarker of enterocyte death, were measured by UHPLC‑MS and ELISA in 154 nondiabetic men and 67 men with a T2D diagnosis.

RESULTS

Plasma citrulline was significantly reduced in men with insulin resistance and T2D compared to insulin sensitive men. Decreased citrulline levels were, however, not observed in men with uncontrolled metabolic parameters during T2D. Plasma I-FABP was significantly higher in men with T2D, especially in presence of uncontrolled glycemic and lipid profile parameters. Integration of both parameters, which estimate enterocyte turnover, was associated with glucose homeostasis as well as with T2D diagnosis. Differences in biomarkers levels were independent of age and BMI and glucose filtration rates.

CONCLUSIONS

Our study supports a decreased functional enterocyte mass and an increased enterocyte death rate in presence of metabolic alterations but emphasizes that epithelial cell homeostasis is especially altered in presence of severe insulin resistance and T2D. The marked changes in small intestine cellularity observed in obesity and diabetes are thus suggested to be part of gut dysfunctions, mainly at an advanced stage of the disease.

Ultra-Early and Early Changes in Bile Acids and Insulin After Sleeve Gastrectomy Among Obese Patients

BACKGROUND AND OBJECTIVE

In obese patients, sleeve gastrectomy (SG) has shown mixed results on bile acid (BA) values. The aim of our study was to examine the potential ultra-early and early changes of the circulating total BA in relation with the changes of insulin resistance (IR) in obese patients submitted to laparoscopic SG. Materials and Methods: Twenty-four obese subjects were investigated for body mass index (BMI), total fasting BA, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), and leptin before and at 7 and 30 d after SG. Results: After surgery, mean BMI decreased at the first (p < 0.001) and at the second time point (p < 0.001) relative to baseline. Total fasting BA values did not change significantly at 7 d (p = 0.938) and at 30 d (p = 0.289) after SG. No significant changes were found at 7 d (p = 0.194, p = 0.34) and 30 d (p = 0.329, p = 0.151) after surgery regarding fasting insulin and HOMA-IR, respectively. However, a trend of increased total fasting BA and decreased fasting insulin and HOMA- after laparoscopic SG has been found. Negative correlations between total fasting BA and insulin (r = -0.807, p = 0.009), HOMA-IR (r = -0.855, p = 0.014), and blood glucose (r = -0.761, p = 0.047), respectively, were observed at one month after SG. Conclusion: In conclusion, here, we found a lack of significant changes in total fasting BA, insulin, and HOMA-IR ultra-early and early after SG, which precluded us to consider a possible relation between the variations of BA and IR. However, the presence of the tendency for total fasting BA to increase and for insulin and HOMA-IR to decrease, as well as of the negative correlations one month after laparoscopic SG, suggest that this surgery brings about some changes that point towards the existence, and possibly towards the restoration, at least to some extent, of the link between BA and glucose metabolism.

Evidence That the Length of Bile Loop Determines Serum Bile Acid Concentration and Glycemic Control After Bariatric Surgery

BACKGROUND

Bariatric surgery contributes to the improvement in glucose metabolism that may be related to a postoperative increase in serum bile acids (BAs). Three commonly used types of bariatric procedures, laparoscopic sleeve gastrectomy (LSG) (without creation of a bile loop), Roux-en-Y gastric bypass (RYGB), and omega-loop gastric bypass (OLGB) (with creation of shorter 100-150 cm and longer 200-280 cm bile loops, respectively), differ in their effects on glycemic control. The aim of the study was to compare the effects of various bariatric procedures on serum BA concentration and glucose homeostasis.

METHODS

Serum BAs in 26 obese patients were determined by liquid chromatography-mass spectrometry prior to bariatric surgery, as well as 4 days and 3 months thereafter.

RESULTS

Four days after the surgery, serum concentrations of BAs in LSG and OLGB groups were similar as prior to the procedure, and a slight decrease in serum BAs was observed in the RYGB group. Serum BA level in the LSG group remained unchanged also at 3 months after the surgery, whereas a significant 0.5- and 3-fold increase in this parameter was noted in the RYGB and OLGB groups, respectively. Serum concentration of BAs correlated positively with the length of the bile loop (R = 0.47, p < 0.05).

CONCLUSION

The evident improvement of glycemic control observed 3 months after OLGB might be associated with a postoperative increase in serum BAs, resulting from their better absorption from the longer bile loop. However, the changes in serum BAs probably had little or no impact on insulin sensitivity improvement at 4 days post-surgery.

Early weight loss in adolescents following bariatric surgery predicts weight loss at 12 and 24 months

BACKGROUND

Growing evidence supports the efficacy of paediatric bariatric surgery. However, there is a paucity of data examining adolescent outcomes post surgery. Among adults, studies have shown that early weight loss is associated with long-term weight loss. Therefore, the aim of our study was to investigate the association between early weight loss at 3 months with longer-term weight loss at 12 and 24 months in adolescents post surgery. We hypothesized that patients who have greater weight loss within the first 3 months will have greater weight loss at 12 and 24 months post surgery.

METHODS

A retrospective chart review of bariatric surgery patients (n = 28) was conducted. Anthropometric measurements at baseline and 3, 12, and 24 months were analysed.

RESULTS

Percent of excess weight loss (%EWL) at 3, 12, and 24 months were 33.6 ± 11.3%, 55.0 ± 20.5%, and 55.1 ± 27.1%, respectively. %EWL at 3 months was positively associated with %EWL at 12 and 24 months (P < 0.05). Receiver operating characteristic curve results identified a cut-off of greater than or equal to 30%EWL at 3 months predicted successful weight loss, defined as greater than or equal to 50%EWL at 12 and 24 months.

CONCLUSION

These findings demonstrate that majority of weight loss among adolescents occurs within the first postoperative year. Greater %EWL by 3 months post surgery predicts successful and sustained weight loss over time.

Effect of Gastrogastric Fistula Closure in Type 2 Diabetes

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) has been shown to significantly improve glucose control in patients with type 2 diabetes (T2DM). The formation of a gastrogastric fistula (GGF) allows nutrients to pass through the native route, rather than bypassing the duodenum in typical RYGB configuration. We sought to evaluate the effect of revisional bariatric surgery for known GGF on control of diabetes.

METHODS

A retrospective chart review of a single academic institution was performed to identify patients who had T2DM at the time of corrective surgery for a GGF. Baseline characteristics, and postoperative outcomes including changes in body mass index (BMI), glycated hemoglobin, fasting blood glucose (FBG), and diabetes medications were assessed.

RESULTS

Ten patients were identified with GGF who had T2DM at the time of corrective surgery. Patients had a male-to-female ratio of 2:3, a mean age of 59.2 ± 10 years, a mean baseline BMI of 38.1 ± 17.6 kg/m², and a median duration of 9 years (interquartile range 6-14) from initial RYGB to revision. At a mean follow-up of 14.9 ± 8.5 months, a mean reduction in BMI of 4.9 ± 6 kg/m² was associated with a significant mean reduction in FBG (167.1 ± 88.2 vs. 106.1 ± 20.4 mg/dL, p = 0.04) and number of diabetes medications (1.4 ± 0.8 vs. 0.7 ± 0.7, p = 0.04).

CONCLUSION

In patients with diabetes and GGF, a corrective surgery for closure of fistula and restoration of bypass anatomy results in improvement of glucose control and status of diabetes medications. This finding can highlight the potential metabolic significance of duodenal exclusion.

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.

The Impact of Bariatric Surgery on Type 2 Diabetes Mellitus and the Management of Hypoglycemic Events

Recent studies discussed the benefit of bariatric surgery on obese patients diagnosed with type 2 diabetes mellitus (T2DM). Several factors play an essential role in predicting the impact of bariatric surgery on T2DM, such as ABCD score (age, BMI, C-peptide, and duration of the disease), HbA1c, and fasting blood glucose, incretins [glucagon-like peptide-1 (GLP-1) and gastric inhibitory peptide (GIP)]. DiaRem score known to include factors such as age, HbA1c, medication, and insulin usage used to predict the remission of T2DM, but it has some limitations. An extensive literature search was conducted on PubMed and Google Scholar using keywords such as gastric bypass, T2DM, bariatric surgery, GLP-1, GIP, and post bariatric hypoglycemia. Restrictive-malabsorptive procedures are most effective in treating T2DM patients based on changes induced in appetite through regulation of gastrointestinal hormones, with decreased hunger and increased satiation. We provide a review of bariatric surgery influence on T2DM and management of post-intervention hypoglycemic events. Post-bariatric surgery hypoglycemia is a serious complication especially when patients develop life-threatening neuroglycopenia with loss of consciousness and seizure. The avoidance of this adverse event may be achieved by strict dietary modification including a restriction on carbohydrates as well as foods with high glycemic index. Further research will provide more information on post-bariatric surgery hyperinsulinemic hypoglycemia pathophysiology and management.