Small intestinal metabolism is central to whole-body insulin resistance

Small Bowel Therapies for Metabolic Disease and Obesity

The small bowel has a crucial role in metabolic homeostasis. Small bowel endoscopic bariatric metabolic treatments (EBMTs) include several devices aimed at providing minimally invasive approaches for the management of metabolic disorders. The aim of this review is to provide an updated and exhaustive overview of the EBMTs targeting the small bowel developed to date, including the duodenal mucosa resurfacing, the duodenal-jejunal bypass liners, gastro-jejunal bypass sleeve, and the incisioneless magnetic anastomosis system, as well as to mention the future perspectives in the field.

Incretin hormones, obesity and gut microbiota

Over the past 40 years, the prevalence of obesity has risen dramatically, reaching epidemic proportions. By 2030 the number of people affected by obesity will reach 1.12 billion worldwide. Gastrointestinal hormones, namely incretins, play a vital role in the pathogenesis of obesity and its comorbidities. GIP (glucose-dependent insulinotropic polypeptide) and GLP-1 (glucagon-like peptide-1), which are secreted from the intestine after nutrient intake and stimulate insulin secretion from pancreatic β cells, influence lipid metabolism, gastric empting, appetite and body weight. The gut microbiota plays an important role in various metabolic conditions, including obesity and type 2 diabetes and influences host metabolism through the interaction with enteroendocrine cells that modulate incretins secretion. Gut microbiota metabolites, such as short-chain fatty acids (SCFAs) and indole, directly stimulate the release of incretins from colonic enteroendocrine cells influencing host satiety and food intake. Moreover, bariatric surgery and incretin-based therapies are associated with increase gut bacterial richness and diversity. Understanding the role of incretins, gut microbiota, and their metabolites in regulating metabolic processes is crucial to develop effective strategies for the management of obesity and its associated comorbidities.

Endoscopic sleeve gastroplasty for metabolic dysfunction-associated steatotic liver disease

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD, formerly nonalcoholic fatty liver disease - NAFLD) is a chronic liver condition linked to obesity and metabolic syndrome. It affects one-third of people globally and, in some cases, can lead to metabolic dysfunction-associated steatohepatitis (MASH, formerly nonalcoholic steatohepatitis, NASH) and fibrosis. Weight loss is crucial for the treatment of MASLD, but diet and lifestyle modifications often fail.

AREAS COVERED

In recent years, endoscopic sleeve gastroplasty (ESG) has gained popularity as an effective and minimally invasive option for obesity treatment, with widespread use worldwide. We present a current overview of the most significant studies conducted on ESG for the management of obesity and MASLD. Our report includes data from published studies that have evaluated the impact of ESG on noninvasive hepatic parameters used to estimate steatosis and fibrosis. However, at present, there are no data available on liver histology.

EXPERT OPINION

ESG has shown promising results in treating MASLD evaluated by noninvasive tests, but current data is limited to small, nonrandomized studies. More research is needed, particularly on the effects of ESG on histologically proven MASH. If future research confirms its efficacy, ESG may be incorporated into treatment guidelines in the future.

Transcriptome analysis suggests broad jejunal alterations in Linghu's obesity-diarrhea syndrome: A pilot study

BACKGROUND

Obesity is associated with a significantly increased risk for chronic diarrhea, which has been proposed as Linghu's obesity-diarrhea syndrome (ODS); however, its molecular mechanisms are largely unknown.

AIM

To reveal the transcriptomic changes in the jejunum involved in ODS.

METHODS

In a cohort of 6 ODS patients (JOD group), 6 obese people without diarrhea (JO group), and 6 healthy controls (JC group), high-throughput sequencing and bioinformatics analyses were performed to identify jejunal mucosal mRNA expression alterations and dysfunctional biological processes. In another cohort of 16 ODS patients (SOD group), 16 obese people without diarrhea (SO group), and 16 healthy controls (SC group), serum diamine oxidase (DAO) and D-lactate (D-LA) concentrations were detected to assess changes in intestinal barrier function.

RESULTS

The gene expression profiles of jejunal mucosa in the JO and JC groups were similar, with only 1 differentially expressed gene (DEG). The gene expression profile of the JOD group was significantly changed, with 411 DEGs compared with the JO group and 211 DEGs compared with the JC group, 129 of which overlapped. The enrichment analysis of these DEGs showed that the biological processes such as digestion, absorption, and transport of nutrients (especially lipids) tended to be up-regulated in the JOD group, while the biological processes such as rRNA processing, mitochondrial translation, antimicrobial humoral response, DNA replication, and DNA repair tended to be down-regulated in the JOD group. Eight DEGs (CDT1, NHP2, EXOSC5, EPN3, NME1, REG3A, PLA2G2A, and PRSS2) may play a key regulatory role in the pathological process of ODS, and their expression levels were significantly decreased in ODS patients (P < 0.001). In the second cohort, compared with healthy controls, the levels of serum intestinal barrier function markers (DAO and D-LA) were significantly increased in all obese individuals (P < 0.01), but were higher in the SOD group than in the SO group (P < 0.001).

CONCLUSION

Compared with healthy controls and obese individuals without diarrhea, patients with Linghu's ODS had extensive transcriptomic changes in the jejunal mucosa, likely affecting intestinal barrier function and thus contributing to the obesity and chronic diarrhea phenotypes.

Intestinal heat shock proteins in metabolic syndrome: Novel mediators of obesity and its comorbidities resolution after metabolic surgery

Over the past 40 years, the prevalence of obesity has risen dramatically, reaching epidemic proportions. Metabolic surgery has proven to be highly effective in treating obesity, leading to significant improvements or complete resolution of obesity-related comorbidities. Research conducted in both animals and humans suggests that the metabolic benefits achieved through metabolic surgery cannot be solely attributed to weight loss. Indeed, there has been an increasing recognition of intestinal inflammation as a novel factor influencing obesity. The gastrointestinal tract is continuously exposed to dietary components, particularly diets rich in saturated fats, which are known to contribute to obesity. It is now widely accepted that heat shock proteins can be released from various cells including intestinal epithelial cells and act as proinflammatory signals. Several studies have shown that circulating levels of glucose-regulated protein 78 (GRP78) are increased in subjects with obesity and correlate with the severity of the disease. Moreover, mice with a partial knockout of GRP78 are protected from diet-induced obesity. In this review, we discuss the role of GRP78 in the development of obesity. Several evidence suggests that GRP78 can influence adipogenesis, lipid droplets stabilization, insulin resistance, and liver steatosis. We also provide an update on GRP78 regulation following metabolic surgery, focusing on the bypass of the small intestine as a key factor for GRP78 secretion. Finally, we discuss the potential role of monoclonal antibodies against GRP78 as a treatment for obesity.

Can liquid biopsies for MASH help increase the penetration of metabolic surgery? A narrative review

This narrative review highlights current evidence on non-invasive tests to predict the presence or absence as well as the severity of metabolic dysfunction-associated steatohepatitis (MASH) and liver fibrosis. Metabolic dysfunction-associated steatotic liver disease (MASLD) is a common condition characterized by fat accumulation in the liver that affects 32 % of the world population. The most severe form of MASLD is MASH in which hepatocyte ballooning and inflammation are present together with steatosis; MASH is often associated with liver fibrosis. MASH diagnosis is determined by invasive liver biopsy. Hence, there is a critical need for non-invasive MASH tests. Plasma biomarkers for MASH diagnosis generally have low sensitivity (62-66 %), and specificity (78-82 %). Monocyte levels of Perilipin2 (PLIN2) predict MASH with an accuracy of 92-93 %, and sensitivity and specificity of 90-95 % and 88-100 %, respectively. This liquid biopsy test can facilitate the study of MASH prevalence in general populations and also monitor the effects of lifestyle, surgical, and pharmacological interventions. Without any FDA-approved MASH therapeutic, and with metabolic surgery markedly surpassing the efficacy of lifestyle modification, an accurate and reliable liquid biopsy could help more people choose surgery as a treatment for MASH.

Laminaria japonica polysaccharide alleviates type 2 diabetes by regulating the microbiota-gut-liver axis: A multi-omics mechanistic analysis

The hypoglycemic effects of low-molecular-weight Laminaria japonica polysaccharide (LJO) were investigated in type 2 diabetes mellitus (T2DM) mice, focusing on its effect on the microbiome, metabolome, and transcriptome. The findings demonstrated that LJO significantly reduced fasting blood glucose levels, insulin levels, and inflammatory factors. Additionally, LJO induced changes in gut microbiota composition and increased the concentrations of cecal short-chain fatty acids. Analysis of transcriptomics and metabolomics data revealed that LJO primarily altered the endocrine and digestive systems, signal transduction, and lipid metabolism. It led to a decrease in palmitic acid levels and an increase in glutathione levels. Real-time quantitative polymerase chain reaction assay suggested that LJO upregulated Irs1 expression, consequently reducing insulin resistance. These findings strongly suggest that LJO holds promise in ameliorating T2DM and may serve as a potential dietary supplement for patients with T2DM.

Surfactant-like photosensitizer for endoscopic duodenal ablation: Modulating meal-stimulated incretin hormones in obese and type 2 diabetes

Duodenal ablation improves glycaemic control and weight loss, so it has been applied using hydrothermal catheters in obese and type 2 diabetes patients, indicating similar mechanisms and therapeutic effects as bariatric surgeries. Endoscopic photodynamic therapy is an innovative procedure that easily accessible to endocrine or gastrointestinal organs, so it is critical for the sprayed photosensitizer (PS) to long-term interact with target tissues for enhancing its effects. Surfactant-like PS was more stable in a wide range of pH and 2.8-fold more retained in the duodenum at 1 h than hydrophilic PS due to its amphiphilic property. Endoscopic duodenal ablation using surfactant-like PS was performed in high fat diet induced rat models, demonstrating body weight loss, enhanced insulin sensitivity, and modulation of incretin hormones. Locoregional ablation of duodenum could affect the profiles of overall intestinal cells secreting meal-stimulated hormones and further the systemic glucose and lipid metabolism, regarding gut-brain axis. Our strategy suggests a potential for a treatment of minimally invasive bariatric and metabolic therapy if accompanied by detailed clinical trials.

The effect of feeding fermented distillers' grains diet on the intestinal metabolic profile of Guanling crossbred cattle

Fermented distiller's grains (FDG)-based diets are nutritious and can improve the growth and intestinal immunity in livestock. However, there is limited research examining the effect of feeding FDG-based diets on changes in intestinal metabolites and related pathways in livestock. In this study, nine Guanling crossbred cattle (Guizhou Guanling Yellow cattle × Simmental cattle) were selected and randomly divided into a basal diet (BD) group and two experimental groups fed with FDG replacing 15% and 30% of the daily ration concentrates (FDG-Case A and FDG-Case B), respectively, with three cattle in each group. Fresh jejunum (J) and cecum (C) tissues were collected for metabolomic analysis. Differential metabolites and metabolic pathways were explored by means of univariate and multivariate statistical analysis. Compared with the J-BD group, 30 and 100 differential metabolites (VIP > 1, p < 0.05) were obtained in the J-FDG-Case A group and J-FDG-Case B group, respectively, and the J-FDG-Case B vs. J-FDG-Case A comparison revealed 63 significantly differential metabolites, which were mainly divided into superclasses including lipids and lipid-like molecules, organoheterocyclic compounds, and organic acids and derivatives. Compared with the C-BD, 3 and 26 differential metabolites (VIP > 1, p < 0.05) were found in the C-FDG-Case A group and C-FDG-Case B group, respectively, and the C-FDG-Case B vs. C-FDG-Case A comparison revealed 21 significantly different metabolites, which were also mainly divided into superclasses including lipids and lipid-like molecules, organoheterocyclic compounds, and organic acids and derivatives. A total of 40 metabolic pathways were identified, with a significance threshold set at p < 0.05. Among them, 2, 14, and 18 metabolic pathways were significantly enriched in the J-FDG-Case A vs. J-BD, J-FDG-Case B vs. J-BD, and J-FDG-Case B vs. J-FDG-Case A comparisons, respectively. Meanwhile, 1, 2, and 3 metabolic pathways were obtained in the C-FDG-Case A vs. C-BD, C-FDG-Case B vs. C-BD, and C-FDG-Case B vs. C-FDG-Case A comparisons, respectively. Furthermore, four significant metabolic pathways, namely insulin resistance, biosynthesis of unsaturated fatty acids, linoleic acid metabolism, and primary bile acid biosynthesis, were significantly enriched in Guanling crossbred cattle fed FDG diets. These results suggest that feeding FDG diets may promote the growth and intestinal immunity of Guanling crossbred cattle by regulating metabolic patterns of lipid compounds and related metabolic pathways. This study sheds light on the potential metabolic regulatory mechanisms of FDG diets and offers some references for their use in livestock feed.

Small intestine-targeted endoscopic bariatrics: Current status and future perspectives

The global obesity epidemic shows no signs of slowing down. Endoscopic bariatric and metabolic therapies (EBMTs) are being increasingly adopted as treatment options for obesity and obesity-related comorbidities, due to their minimally invasive nature and ease of delivery. According to the site of action along the gastrointestinal tract, EBMTs can be divided into two categories: gastric EBMTs, and small intestine-targeted EBMTs. Unlike gastric EBMTs, which work through a volume-restricting mechanism leading to early satiety and reduced caloric intake, small intestine-targeted EBMTs can be metabolically beneficial through foregut and/or hindgut pathways independent of weight loss, and therefore have great potential for the treatment of obesity-related metabolic comorbidities such as type 2 diabetes. Although none of the small intestine-targeted EBMTs have been approved by the US Food and Drug Administration to date, their clinical efficacy and safety have been extensively explored in investigational trials. This review aims to summarize and provide a comprehensive understanding of small intestine-targeted EBMTs in clinical and preclinical settings, and to further discuss their potential mechanisms of action.

Mechanisms of bariatric surgery for weight loss and diabetes remission

Obesity and type 2 diabetes(T2D) lead to defects in intestinal hormones secretion, abnormalities in the composition of bile acids (BAs), increased systemic and adipose tissue inflammation, defects of branched-chain amino acids (BCAAs) catabolism, and dysbiosis of gut microbiota. Bariatric surgery (BS) has been shown to be highly effective in the treatment of obesity and T2D, which allows us to view BS not simply as weight-loss surgery but as a means of alleviating obesity and its comorbidities, especially T2D. In recent years, accumulating studies have focused on the mechanisms of BS to find out which metabolic parameters are affected by BS through which pathways, such as which hormones and inflammatory processes are altered. The literatures are saturated with the role of intestinal hormones and the gut-brain axis formed by their interaction with neural networks in the remission of obesity and T2D following BS. In addition, BAs, gut microbiota and other factors are also involved in these benefits after BS. The interaction of these factors makes the mechanisms of metabolic improvement induced by BS more complicated. To date, we do not fully understand the exact mechanisms of the metabolic alterations induced by BS and its impact on the disease process of T2D itself. This review summarizes the changes of intestinal hormones, BAs, BCAAs, gut microbiota, signaling proteins, growth differentiation factor 15, exosomes, adipose tissue, brain function, and food preferences after BS, so as to fully understand the actual working mechanisms of BS and provide nonsurgical therapeutic strategies for obesity and T2D.

Temporal Relationship Between Insulin Resistance and Lipid Accumulation After Bariatric Surgery: a Multicenter Cohort Study

PURPOSE

Insulin resistance (IR) is closely associated with lipid accumulation. Here, we investigated the temporal relationship between the two conditions after bariatric surgery.

MATERIALS AND METHODS

In total, 409 participants were enrolled from three bariatric centers in China from 2009 to 2018. We evaluated whether baseline IR (proxied by homeostasis model assessment of insulin resistance (HOMA-IR)) and lipid accumulation (proxied by visceral adiposity index (VAI) and lipid accumulation product (LAP)) were associated with follow-up IR and lipid accumulation (3 months postoperatively) using linear regression models. We then conducted a cross-lagged panel analysis model to simultaneously examine the bidirectional relationship between IR and lipid accumulation.

RESULTS

Multivariable linear regression analyses showed that baseline HOMA-IR was associated with follow-up VAI (β = 0.430, 95% CI: 0.082-0.778, p = 0.016) and LAP (β = 0.070, 95% CI: 0.010-0.130, p = 0.022). There was no relationship between baseline lipid accumulation and follow-up IR. Further cross-lagged panel analyses indicated that the path coefficient from baseline HOMA-IR to follow-up VAI (β₂ = 0.145, p = 0.003) was significantly greater than the coefficient from baseline VAI to follow-up HOMA-IR (β₁ =  - 0.013, p = 0.777). Similarly, the path coefficient from baseline HOMA-IR to follow-up LAP (β₂ = 0.141, p = 0.003) was significantly greater than the coefficient from baseline LAP to follow-up HOMA-IR (β₁ = 0.041, p = 0.391).

CONCLUSION

Our study demonstrated a unidirectional relationship from HOMA-IR to VAI and LAP, suggesting that the change in IR may precede lipid accumulation after surgery.

Glucose metabolism after bariatric surgery: implications for T2DM remission and hypoglycaemia

Although promising therapeutics are in the pipeline, bariatric surgery (also known as metabolic surgery) remains our most effective strategy for the treatment of obesity and type 2 diabetes mellitus (T2DM). Of the many available options, Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) are currently the most widely used procedures. RYGB and VSG have very different anatomical restructuring but both surgeries are effective, to varying degrees, at inducing weight loss and T2DM remission. Both weight loss-dependent and weight loss-independent alterations in multiple tissues (such as the intestine, liver, pancreas, adipose tissue and skeletal muscle) yield net improvements in insulin resistance, insulin secretion and insulin-independent glucose metabolism. In a subset of patients, post-bariatric hypoglycaemia can develop months to years after surgery, potentially reflecting the extreme effects of potent glucose reduction after surgery. This Review addresses the effects of bariatric surgery on glucose regulation and the potential mechanisms responsible for both the resolution of T2DM and the induction of hypoglycaemia.

Upper gut heat shock proteins HSP70 and GRP78 promote insulin resistance, hyperglycemia, and non-alcoholic steatohepatitis

A high-fat diet increases the risk of insulin resistance, type-2 diabetes, and non-alcoholic steato-hepatitis. Here we identified two heat-shock proteins, Heat-Shock-Protein70 and Glucose-Regulated Protein78, which are increased in the jejunum of rats on a high-fat diet. We demonstrated a causal link between these proteins and hepatic and whole-body insulin-resistance, as well as the metabolic response to bariatric/metabolic surgery. Long-term continuous infusion of Heat-Shock-Protein70 and Glucose-Regulated Protein78 caused insulin-resistance, hyperglycemia, and non-alcoholic steato-hepatitis in rats on a chow diet, while in rats on a high-fat diet continuous infusion of monoclonal antibodies reversed these phenotypes, mimicking metabolic surgery. Infusion of these proteins or their antibodies was also associated with shifts in fecal microbiota composition. Serum levels of Heat-Shock-Protein70 and Glucose-Regulated Protein78were elevated in patients with non-alcoholic steato-hepatitis, but decreased following metabolic surgery. Understanding the intestinal regulation of metabolism may provide options to reverse metabolic diseases.

Physiopathology of nonalcoholic fatty liver disease: from diet to nutrigenomics

PURPOSE OF REVIEW

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide and is strongly associated with metabolic disorders, such as obesity, type 2 diabetes mellitus, and metabolic syndrome, to the extent that a new definition of metabolic associated fatty liver disease has been proposed.

RECENT FINDINGS

Insulin resistance, worsened by a high-fat and high-carbohydrate diet, is the key to the physiopathology of hepatic steatosis. This is driven by several mechanisms that are mostly activated at a genetic level, such as de-novo lipogenesis and triglyceride synthesis. Therefore, many diet regimens have been studied, although significant controversies remain regarding their metabolic effects and long-term sustainability.

SUMMARY

In this review, we summarized the role and effects of the main macronutrients on the development of NAFLD and discussed the molecular mechanisms involved. We also discussed the importance of genetic polymorphisms, epigenetic alterations, and dysbiosis to determine if lifestyle modification and a specific dietary regimen could be an essential part of NAFLD treatment.

Anti-Diabetic Effects of Ethanol Extract from Sanghuangporous vaninii in High-Fat/Sucrose Diet and Streptozotocin-Induced Diabetic Mice by Modulating Gut Microbiota

Type 2 diabetes mellitus (T2DM) may lead to abnormally elevated blood glucose, lipid metabolism disorder, and low-grade inflammation. Besides, the development of T2DM is always accompanied by gut microbiota dysbiosis and metabolic dysfunction. In this study, the T2DM mice model was established by feeding a high-fat/sucrose diet combined with injecting a low dose of streptozotocin. Additionally, the effects of oral administration of ethanol extract from Sanghuangporous vaninii (SVE) on T2DM and its complications (including hypoglycemia, hyperlipidemia, inflammation, and gut microbiota dysbiosis) were investigated. The results showed SVE could improve body weight, glycolipid metabolism, and inflammation-related parameters. Besides, SVE intervention effectively ameliorated the diabetes-induced pancreas and jejunum injury. Furthermore, SVE intervention significantly increased the relative abundances of Akkermansia, Dubosiella, Bacteroides, and Parabacteroides, and decreased the levels of Lactobacillus, Flavonifractor, Odoribacter, and Desulfovibrio compared to the model group (LDA > 3.0, p < 0.05). Metabolic function prediction of the intestinal microbiota by PICRUSt revealed that glycerolipid metabolism, insulin signaling pathway, PI3K-Akt signaling pathway, and fatty acid degradation were enriched in the diabetic mice treated with SVE. Moreover, the integrative analysis indicated that the key intestinal microbial phylotypes in response to SVE intervention were strongly correlated with glucose and lipid metabolism-associated biochemical parameters. These findings demonstrated that SVE has the potential to alleviate T2DM and its complications by modulating the gut microbiota imbalance.

Gut Microbiome in Non-Alcoholic Fatty Liver Disease: From Mechanisms to Therapeutic Role

Non-alcoholic fatty liver disease (NAFLD) is considered to be a significant health threat globally, and has attracted growing concern in the research field of liver diseases. NAFLD comprises multifarious fatty degenerative disorders in the liver, including simple steatosis, steatohepatitis and fibrosis. The fundamental pathophysiology of NAFLD is complex and multifactor-driven. In addition to viruses, metabolic syndrome and alcohol, evidence has recently indicated that the microbiome is related to the development and progression of NAFLD. In this review, we summarize the possible microbiota-based therapeutic approaches and highlight the importance of establishing the diagnosis of NAFLD through the different spectra of the disease via the gut–liver axis.

Glucose Tolerance after Pancreatectomy: A Prospective Observational Follow-Up Study of Pancreaticoduodenectomy and Distal Pancreatectomy

BACKGROUND

Effects of pancreatectomy on glucose tolerance have not been clarified, and evidence regarding the difference in postoperative glucose tolerance between pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) is lacking.

STUDY DESIGN

This prospective, single-center observational study analyzed 40 patients undergoing PD and 29 patients undergoing DP (Clinical trial registry number UMIN000008122). Glucose tolerance, including insulin secretion (Δ C-peptide immunoreactivity, ΔCPR) and insulin resistance (homeostasis model assessment of insulin resistance, HOMA-IR) were assessed before and 1 month after pancreatectomy using the oral glucose tolerance test (OGTT) and glucagon stimulation test. We assessed long-term hemoglobin A1c (HbA1c) levels in patients, with a follow-up time of 3 years.

RESULTS

Percentages of patients diagnosed with abnormal OGTT decreased after PD (from 12 [30%] to 7 [17.5%] of 40 patients, p = 0.096); however, they increased after DP (from 4 [13.8%] to 8 [27.6%] of 29 patients, p = 0.103), although the changes were not statistically significant. ΔCPR decreased after both PD (from 3.2 to 1.0 ng/mL, p < 0.001) and DP (from 3.3 to 1.8 ng/mL, p < 0.001). HOMA-IR decreased after PD (from 1.10 to 0.68, p < 0.001), but did not change after DP (1.10 and 1.07, p = 0.42). Median HbA1c level was higher after DP than after PD for up to 3 years, but the differences were not statistically significant.

CONCLUSIONS

In comparisons of pre- and 1 month post-pancreatectomy data, glucose tolerance showed improvement after PD, whereas it worsened after DP. Insulin secretion decreased after both PD and DP. Insulin resistance improved after PD, but did not change after DP. Further studies are warranted to clarify mechanisms of improved insulin resistance after PD.

Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-up of an open-label, single-centre, randomised controlled trial

BACKGROUND

No data from randomised controlled trials of metabolic surgery for diabetes are available beyond 5 years of follow-up. We aimed to assess 10-year follow-up after surgery compared with medical therapy for the treatment of type 2 diabetes.

METHODS

We did a 10-year follow-up study of an open-label, single-centre (tertiary hospital in Rome, Italy), randomised controlled trial, in which patients with type 2 diabetes (baseline duration >5 years; glycated haemoglobin [HbA_1c] >7·0%, and body-mass index ≥35 kg/m²) were randomly assigned (1:1:1) to medical therapy, Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion (BPD) by a computerised system. The primary endpoint of the study was diabetes remission at 2 years (HbA_1c <6·5% and fasting glycaemia <5·55 mmol/L without ongoing medication for at least 1 year). In the 10-year analysis, durability of diabetes remission was analysed by intention to treat (ITT). This study is registered with ClinicalTrials.gov, NCT00888836.

FINDINGS

Between April 30, 2009, and Oct 31, 2011, of 72 patients assessed for eligibility, 60 were included. The 10-year follow-up rate was 95·0% (57 of 60). Of all patients who were surgically treated, 15 (37·5%) maintained diabetes remission throughout the 10-year period. Specifically, 10-year remission rates in the ITT population were 5·5% for medical therapy (95% CI 1·0-25·7; one participant went into remission after crossover to surgery), 50·0% for BPD (29·9-70·1), and 25·0% for RYGB (11·2-46·9; p=0·0082). 20 (58·8%) of 34 participants who were observed to be in remission at 2 years had a relapse of hyperglycaemia during the follow-up period (BPD 52·6% [95% CI 31·7-72·7]; RYGB 66·7% [41·7-84·8]). All individuals with relapse, however, maintained adequate glycaemic control at 10 years (mean HbA_1c 6·7% [SD 0·2]). Participants in the RYGB and BPD groups had fewer diabetes-related complications than those in the medical therapy group (relative risk 0·07 [95% CI 0·01-0·48] for both comparisons). Serious adverse events occurred more frequently among participants in the BPD group (odds ratio [OR] for BPD vs medical therapy 2·7 [95% CI 1·3-5·6]; OR for RYGB vs medical therapy 0·7 [0·3-1·9]).

INTERPRETATION

Metabolic surgery is more effective than conventional medical therapy in the long-term control of type 2 diabetes. Clinicians and policy makers should ensure that metabolic surgery is appropriately considered in the management of patients with obesity and type 2 diabetes.

FUNDING

Fondazione Policlinico Universitario Agostino Gemelli IRCCS.

Endobariatric procedures for obesity: clinical indications and available options

Obesity remains a growing public health epidemic that has increased healthcare costs and related comorbidities. Current treatment guidelines encourage a multidisciplinary approach starting from patient selection, interventions, and long-term follow-up to maintain weight loss. However, these conservative interventions are largely ineffective at reducing body weight due to low adherence to the treatment regimen. Recently, endoscopic bariatric therapies have become an attractive alternative to traditional invasive bariatric surgeries due to their improved efficacy, safety, and cost-effectiveness. Endoscopic bariatric therapies include intragastric balloon placement, endoscopic sleeve gastroplasty, gastric bypass revision, and aspiration therapy. These procedures fall into two separate categories depending on the primary mechanism involved: restrictive or malabsorptive. Restrictive methods, such as the Orbera® and ReShape™ intragastric balloons, increase satiation and delay gastric emptying while decreasing the amount of food that can be ingested. In contrast, malabsorptive devices, such as the EndoBarrier®, interfere with the small intestine's ability to absorb food while restoring normal gastrointestinal hormone levels regulating satiation. Together, these techniques provide useful alternatives for patients in whom pharmacological or lifestyle modifications have proven ineffective. Despite these advantages, the long-term effects of these procedures on metabolic changes remain to be studied. Furthermore, the management of complications from these procedures continues to evolve. In this review, we aim to elaborate on the clinical indications and efficacy of the endobariatric procedures, together with various types of available endoscopic bariatric therapy procedures.