Bariatric surgery reduces oxidative stress by blunting 24-h acute glucose fluctuations in type 2 diabetic obese patients

Association Between Dietary Intake After Roux-en-Y Gastric Bypass Surgery and Antioxidant/inflammatory Status: A 6-Month Pilot Prospective Cohort Study

BACKGROUND/AIM

Adipose tissue can increase levels of inflammation and oxidative stress, which explains the relationship between obesity and many chronic diseases. Weight loss, changes in adipose tissue metabolism, and dietary nutrient intake changes following bariatric surgery could affect a number of oxidative- and inflammation-related factors. Therefore, this study aimed to assess the potential relationship between dietary intake and inflammatory/antioxidant markers in the 6 months following Roux-en-Y gastric bypass surgery (RYGB).

MATERIAL AND METHODS

This pilot prospective cohort study included 45 patients with severe obesity who underwent RYGB. The patients were assessed at three different time points: baseline, 3 months, and 6 months post-surgery. Throughout the study, dietary intake data, levels of total antioxidant capacity (TAC), NF-κB, and serum levels of certain micronutrients were measured three times. Dietary macro- and micronutrient intake data were obtained three times throughout the study using the 24-h food recall questionnaire.

RESULTS

The analysis of dietary indices in the present study found a significant positive correlation between the dietary intake of zinc, copper, MUFA, and serum TAC levels. It also revealed a significant inverse correlation between serum levels of NF-κB with vitamin E and PUFA intake. Additionally, there was a significant positive association between the amount of dietary carbohydrates and saturated fatty acids intake and the levels of NF-κB. Furthermore, within 3 to 6 months after the surgery, patients experienced an increase in serum levels of TAC, ferritin, vitamin D3, vitamin B12, and folate. However, there was a decrease in serum levels of NF-κB, zinc, and copper.

CONCLUSIONS

Weight loss and nutritional status may potentially impact oxidative stress and inflammation levels within 6 months following RYGB surgery. Further research is necessary to comprehensively investigate the different facets of this correlation and elucidate the precise underlying mechanism.

Analysis of the Relationship between Physical Activity and the Factors Related to Weight Management of Bariatric Surgery Patients

Background

We aimed to analyze the relationship between physical activity and the factors related to the weight management of bariatric surgery patients.

Methods

This descriptive-correlational study was conducted on 87 participants, who underwent bariatric surgery in Cyprus between May and Oct 2020. The International Physical Activity Questionnaire and a questionnaire on socio-demographic and obesity characteristics were used to collect data.

Results

Mean age of the participants was 34.7±8.43 and 65.5% were female. A statistically significant difference was found between physical activity levels and weight loss (P=0.021). Post-bariatric surgery physical activity level was low active for 65.5% of the participants. There was a statistically significant difference between the MET scores of the participants according to their gender, and the scores of men were higher than women (2256.9; 1110.9 respectively). Although most of the participants in the study were females, women lost less weight than males (45.5; 54.2 respectively).

Conclusion

Being female, married, and having chronic diseases caused less weight loss after bariatric surgery. As the physical activity levels of the patients increased, their weight loss increased. In line with these results, people undergone bariatric surgery and are at risk of regaining weight should be followed closely after surgery and appropriate physical activities should be planned.

Serum Glucose Variability Increases the Risk of Complications Following Aseptic Revision Hip and Knee Arthroplasty

BACKGROUND

Increased serum glucose variability has been proposed as a risk factor for perioperative morbidity and mortality. Given the greater surgical complexity and complication risk of revision total joint arthroplasty (TJA), previous findings may not be generalizable to the revision population. The purpose of this study was to investigate the association between glucose variability and postoperative complications following aseptic revision TJA.

METHODS

We identified 1,983 patients who underwent an aseptic revision TJA (636 total knee arthroplasties [TKAs] and 1,347 total hip arthroplasties [THAs]) from 2001 to 2019. Patients with ≥2 postoperative glucose values per day or ≥3 values during hospitalization were included in this study. Glucose variability was assessed using the coefficient of variation (COV). Outcomes included length of hospital stay, 90-day complications, mortality, and periprosthetic joint infection (PJI) as defined by the 2018 International Consensus Meeting criteria. Multivariate regression was used to determine the association between glucose variability and each end point, using COV as continuous and categorical variables (that is, COV tertiles).

RESULTS

Patients with high glycemic variability were at 1.7 times greater risk for 90-day complications (odds ratio [OR], 1.664 [95% confidence interval (CI), 1.266 to 2.188]; p < 0.001) and 2 times greater risk for PJI at a minimum 1-year follow-up (OR, 1.984 [95% CI, 1.270 to 3.100]; p = 0.003). The risk of 90-day complications increased by 2.2% (OR, 1.022 [95% CI, 1.012 to 1.032]; p < 0.001) and the risk of PJI increased by 1.8% (OR, 1.018 [95% CI, 1.003 to 1.034]; p = 0.013) for every percentage-point increase in COV. Patients with higher glucose variability also had a longer length of stay (beta, 1.028 days [95% CI, 0.590 to 1.466 days]; p < 0.001). These associations were independent of age, sex, body mass index, Charlson Comorbidity Index, involved joint, operative time, history of diabetes, and mean glucose levels.

CONCLUSIONS

Higher glucose variability was associated with an increased risk of medical complications and PJI following aseptic revision TJA. Patients undergoing these complex procedures should have glucose levels monitored closely in the perioperative period. Future studies should evaluate the utility of continuous glucose monitoring in this high-risk population.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Multiple Complex Complications After Redo Bariatric Surgery (Infrequent Complication: Fistula Between the Splenic Artery and the Remnant of the Stomach): A Case Report

With the epidemic prevalence of obesity in today’s society, bariatric surgery has become very popular in treating severe obesity. Although the complications of this surgery have decreased with the advancement of medicine and post-treatment care, there are still complications that can lead to death if neglected. In this case report, we present a 44-year-old patient who underwent redo bariatric surgery. She was discharged from the hospital in good general condition but returned a few days later with a major complaint of abdominal pain and sudden bleeding from the upper gastrointestinal tract. After performing CT and endoscopy and considering the results, the patient underwent laparotomy, which showed a fistula between the splenic artery and the remnant of the stomach. After surgery and after the recovery period, the patient was discharged from the hospital. In this case report, we describe for the first time an uncommon and unique complication following redo bariatric surgery. We suggest that a fistula between the splenic artery and the remnant of the stomach should be considered in patients with abdominal pain and upper gastrointestinal bleeding who underwent redo bariatric surgery.

It is really time to retire laparoscopic gastric banding? Positive outcomes after long-term follow-up: the management is the key

After the initial widespread diffusion, laparoscopic adjustable gastric banding (LAGB) has been progressively abandoned and laparoscopic sleeve gastrectomy (LSG) has become the worldwide most adopted procedure. Nevertheless, recent reports raised concerns about the long-term weight regain after different bariatric techniques. Considering the large LAGB series recorded in our multicentric bariatric database, we analysed the anthropometric and surgical outcomes of obese patients underwent LAGB at a long-term follow-up, focusing on LAGB management. Between January 2008 to January 2018, demographics, anthropometric and post-operative data of obese patients undergone LAGB were retrospectively evaluated. To compare the postoperative outcomes, the cohort was divided in two groups according to the quantity of band filling (QBF): low band filling group (Group 1) with at most 3 ml of QBF, and patients in the high band filling group (Group 2) with at least 4 ml. 699 obese patients were considered in the analysis (351 in Group 1 and 348 in Group 2). Patients in Group 1 resulted significantly associated (p < 0.05) to higher % EWL and quality of life score (BAROS Score), 49.1 ± 11.3 vs 38.2 ± 14.2 and 5.9 ± 1.8 vs 3.8 ± 2.5, respectively. Moreover, patients with lower band filling (Group 1) complained less episodes of vomiting, epigastric pain and post-prandial reflux and significantly decreased slippage and migration rate (p < 0.001 for all parameters). LAGB is a safe and reversible procedure, whose efficacy is primarily related to correct postoperative handling. Low band filling and strict follow-up seem the success' key of this technique, which deserves full consideration among bariatric procedures.

The liver-alpha-cell axis after a mixed meal and during weight loss in type 2 diabetes

OBJECTIVE

Glucagon and amino acids may be regulated in a feedback loop called the liver-alpha-cell axis with alanine or glutamine as suggested signal molecules. We assessed this concept in individuals with type 2 diabetes in the fasting state, after ingestion of a protein-rich meal, and during weight loss. Moreover, we investigated if postprandial glucagon secretion and hepatic insulin sensitivity were related.

METHODS

This is a secondary analysis of a 12-week weight-loss trial (Paleolithic diet ± exercise) in 29 individuals with type 2 diabetes. Before and after the intervention, plasma glucagon and amino acids were measured in the fasting state and during 180 min after a protein-rich mixed meal. Hepatic insulin sensitivity was measured using the hyperinsulinemic-euglycemic clamp with [6,6-2H2]glucose as a tracer.

RESULTS

The postprandial increase of plasma glucagon was associated with the postprandial increase of alanine and several other amino acids but not glutamine. In the fasted state and after the meal, glucagon levels were negatively correlated with hepatic insulin sensitivity (rS = -0.51/r = -0.58, respectively; both P < 0.05). Improved hepatic insulin sensitivity with weight loss was correlated with decreased postprandial glucagon response (r = -0.78; P < 0.001).

CONCLUSIONS

Several amino acids, notably alanine, but not glutamine could be key signals to the alpha cell to increase glucagon secretion. Amino acids may be part of a feedback mechanism as glucagon increases endogenous glucose production and ureagenesis in the liver. Moreover, postprandial glucagon secretion seems to be tightly related to hepatic insulin sensitivity.

Increased postoperative glucose variability is associated with adverse outcomes following orthopaedic surgery

Aims

The aim of this study was to examine the association between postoperative glycaemic variability and adverse outcomes following orthopaedic surgery.

Patients and Methods

This retrospective study analyzed data on 12 978 patients (1361 with two operations) who underwent orthopaedic surgery at a single institution between 2001 and 2017. Patients with a minimum of either two postoperative measurements of blood glucose levels per day, or more than three measurements overall, were included in the study. Glycaemic variability was assessed using a coefficient of variation (CV). The length of stay (LOS), in-hospital complications, and 90-day readmission and mortality rates were examined. Data were analyzed with linear and generalized linear mixed models for linear and binary outcomes, adjusting for various covariates.

Results

The cohort included 14 339 admissions, of which 3302 (23.0%) involved diabetic patients. Patients with CV values in the upper tertile were twice as likely to have an in-hospital complication compared with patients in the lowest tertile (19.4% versus 9.0%, p < 0.001), and almost five times more likely to die compared with those in the lowest tertile (2.8% versus 0.6%, p < 0.001). Results of the adjusted analyses indicated that the mean LOS was 1.28 days longer in the highest versus the lowest CV tertile (p < 0.001), and the odds of an in-hospital complication and 90-day mortality in the highest CV tertile were respectively 1.91 (p < 0.001) and 2.10 (p = 0.001) times larger than the odds of these events in the lowest CV tertile. These associations were significant even for non-diabetic patients. After adjusting for hypoglycaemia, the relationships remained significant, except that the CV tertile no longer predicted mortality in diabetics.

Conclusion

These results indicate that higher glycaemic variability is associated with longer LOS and in-hospital complications. Glycaemic variability also predicted death, although that primarily held for non-diabetic patients in the highest CV tertile following orthopaedic surgery. Prospective studies should examine whether ensuring low postoperative glycaemic variability may reduce complication rates and mortality. Cite this article: Bone Joint J 2018;100-B:1125–32.

All Patients Should Be Screened for Diabetes Before Total Joint Arthroplasty

BACKGROUND

Diabetes is highly prevalent in patients with osteoarthritis before total joint arthroplasty and presents a higher risk of adverse postoperative outcomes. However, the rate of diabetes in this population and optimal screening strategies remain unknown.

METHODS

We prospectively screened patients undergoing elective total joint arthroplasty for diabetes using glycated hemoglobin (HbA1c) and fasting blood glucose (FBG) levels. Screening was conducted within 2 time periods between 2012 and 2017. The prevalence of diabetes was assessed using a previous diagnosis of diabetes or, in the absence of diagnosis, by measuring if HbA1c ≥ 6.5% or FBG ≥ 126 mg/dL. Prediabetes was defined as 5.7% ≤ HbA1c ≤ 6.4% or 100 mg/dL ≤ FBG ≤ 125 mg/dL. Occurrence of a 90-day periprosthetic joint infection and wound complications was noted.

RESULTS

A total of 1461 patients were included in the study. The prevalence of diabetes was 20.6%; 178 patients (59.1%) had diagnosed diabetes, and 123 patients (40.9%) had undiagnosed diabetes. Prediabetes was identified in 559 patients (38.3%), resulting in a combined total of 860 (58.9%) patients with diabetes and prediabetes. Total diabetic rates were significantly higher in patients aged >65 years, of nonwhite ethnicity, and undergoing total knee arthroplasty. No significant differences in periprosthetic joint infection and wound complications were observed while comparing patients with diagnosed and undiagnosed diabetes.

CONCLUSION

A significant proportion of patients with undiagnosed diabetes and prediabetes were identified. Preadmission testing provides an opportunity to identify and address this condition, potentially reducing short-term arthroplasty-related complications and avoiding long-term systemic diabetic complications. We strongly recommend universal glycemic screening to all elective arthroplasty patients.

The role of glucagon in weight loss-mediated metabolic improvement: a systematic review and meta-analysis

Aims This meta-analysis aimed to investigate the role of glucagon suppression in regulating glucose homeostasis following diet or bariatric surgery. Methods A comprehensive search of intervention and observational studies was conducted in Medline, Scopus, Web of Science, PubMed and Embase. Random effects model meta-analysis was performed. Primary outcomes were (i) body weight change, (ii) fasting glucagon, (iii) fasting glucose and (iv) fasting insulin concentrations. Results Twenty articles reporting data from 29 interventions were eligible for analysis. Bariatric surgery caused greater weight loss than diet (bariatric -29.7 kg [CI:-36.8, -22.6]; diet -5.8 kg [CI: -8.4, -3.3]; P < 0.00001), an effect that remained significant after adjusting for study duration (P < 0.05). Mean fasting glucagon decreased in parallel with weight loss (-11.8 ng/L [CI: -15.9, -7.8]; P < 0.00001) with no difference between bariatric and diet intervention. Both fasting glucose, and insulin decreased following weight loss (both P < 0.00001; glucose -1.7 mmol/L [CI: -2.0, -1.3]; insulin -50.6 pmol/L [CI: -66.5, -34.7] with greater decrease in fasting insulin between bariatric versus diet (P = 0.01). Conclusions Synergistic suppression of fasting glucagon and insulin resistance may act together to restore normoglycaemia following weight loss. Whether suppression of plasma glucagon may contribute to increased hunger after weight loss and gradual weight regain is not yet known.

Dietary Weight Loss, Exercise, and Oxidative Stress in Postmenopausal Women: A Randomized Controlled Trial

Oxidative stress, a potential mechanism linking obesity and cancer, results from an imbalance between activation/inactivation of reactive oxygen species, byproducts of cellular metabolism. In a randomized controlled trial, we investigated effects of diet and/or exercise on biomarkers of oxidative stress. A total of 439 overweight/obese [body mass index (BMI) > 25 kg/m²] postmenopausal women, ages 50 of 75 years, were randomized to 12 months of (i) reduced-calorie weight loss diet ("diet"; n = 118); (ii) moderate-to-vigorous intensity aerobic exercise ("exercise"; n = 117); (iii) combined diet and exercise intervention ("diet + exercise"; n = 117); or (iv) control (n = 87). Outcomes were circulating markers of oxidative stress, including fluorescent oxidation products (FOP), F₂-isoprostanes, and oxidized low-density lipoprotein (LDL). On average, participants were 57.9 years, with a BMI of 30.9 kg/m² F₂-isprostanes were significantly reduced in the diet (-22.7%, P = 0.0002) and diet + exercise (-23.5%, P < 0.0001) arms versus controls (-2.99%) and nonsignificantly reduced in the exercise arm (-14.5%, P = 0.01). Participants randomized to the diet and diet + exercise arms had significant increases in levels of FOP [control -5.81%; diet +14.77% (P = 0.0001); diet + exercise +17.45%, (P = 0.0001)]. In secondary analyses, increasing weight loss was statistically significantly associated with linear trends of greater reductions in oxidized LDL and in F₂-isoprostanes and increases in FOP. Compared with controls, exercise participants whose maximal oxygen consumption increased had significant decreases in levels of F₂-isoprostanes and in oxidized LDL and increases in FOP. Dietary weight loss, with or without exercise, significantly reduced some markers of oxidative stress in postmenopausal women. Cancer Prev Res; 9(11); 835-43. ©2016 AACR.

"Dual-remission" after Roux-en-Y gastric bypass surgery: Glycemic variability cannot always be improved in Chinese obese patients with type 2 diabetes

BACKGROUND

Glycemic variability after Roux-en-Y Gastric Bypass (RYGB) has not been adequately examined in Chinese obese patients with type 2 diabetes (T2D).

OBJECTIVE

We aimed to evaluate glucose variability after RYGB by continuous glucose monitoring (CGM) and then evaluate the remission rate based on the complete diabetes remission criteria combined with normal ranges of CGM for the Chinese population, which we defined as "dual-remission."

SETTING

The study was done at our academic university-affiliated hospital.

METHODS

Over a 3-day period, CGM was performed on 43 Chinese obese T2D patients combined with a mixed-meal test before and 1 year after RYGB. Mean amplitude of glucose excursions (MAGE), standard deviations (SD), and the time that patients' blood glucose levels were≥7.0 mmol/L,≥7.8 mmol/L,≥11.1 mmol/L, and≤3.9 mmol/L within 24 hours was analyzed. Multiple logistic regression analyses were used to identify predictors of "dual-remission."

RESULTS

Complete diabetes remission was achieved in 27 patients (62.8%) 1 year after RYGB. However, MAGE didn't change in the group, and only 18.6% patients met "dual-remission." Compared with patients in the complete remission group, patients in the dual-remission group had a shorter duration of diabetes, younger age, lower glycated hemoglobin (HbA1c) level, and no insulin usage at baseline. Correlation analysis showed MAGE after RYGB was positively correlated with diabetes duration (r = .43, P<.01). Multiple logistic regressions indicated a shorter duration was associated with a higher possibility to achieve dual-remission after adjusting for age, gender, HbA1c, and insulin therapy.

CONCLUSION

Glucose variability can't be effectively improved in most Chinese obese diabetic patients after RYGB. Shorter diabetes duration was associated with higher possibility to achieve "dual-remission."

Sleeve gastrectomy improves obstructive sleep apnea syndrome (OSAS): 5 year longitudinal study

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is prevalent among morbidly obese patients. Evaluation of the specific effects of sleeve gastrectomy (SG) on upper airway function has not been reported. Given the possibility that some patients will not respond despite weight loss, no studies have investigated whether other mechanisms may be responsible for persistent OSAS after bariatric surgery.

OBJECTIVES

To evaluate by subjective and objective assessment the impact of SG on upper respiratory physiology in the long-term.

SETTING

University Hospital, Division of Bariatric and ENT Surgery, in Italy.

METHODS

Thirty-six consecutive patients with OSAS who underwent laparoscopic SG were prospectively enrolled. The effect of SG on respiratory function and OSAS was followed for 5 years.

RESULTS

All patients completed the 5-year follow-up. A significant (P<.001) improvement in modified Epworth Sleepiness Scale questionnaire (ESS) was obtained in 91.6% (33/36) of patients. The Apnea/Hypopnea index (AHI) improved in 80.6% (29/36) of patients after surgery (from 32.8 ± 1.7 to 5.8 ± 1.2 (P<.001), 4.9 ± 1.7). The remaining 19.4% (7/36) of patients with a positive ESS and/or AHI all had an associated respiratory resistance due to nasal obstructive diseases.

CONCLUSION

SG improved OSAS overall, but patients who did not improve or only partially improved despite weight loss were found to have an associated nasal responsible pathology. How these patients will respond to nasal surgery and whether a 2-step procedure should be recommended for OSAS patients requires further study.

Nitrosative stress but not glycemic parameters correlate with improved neuropathy in nonseverely obese diabetic patients after Roux-Y gastric bypass

BACKGROUND

Diabetic neuropathy is common in type 2 diabetic patients (T2DM) but tight glycemic control does not improve the symptoms. In contrast, Roux-Y gastric bypass (RYGB) has a positive effect on active neuropathic symptoms, independent from glycemic control. The purpose of the present study was to identify potential mechanisms of improved diabetic neuropathic symptoms after RYGB.

METHODS

A prospective cohort of 20 patients with insulin-dependent T2DM and BMI < 35 kg/m(2) were treated with RYGB. Nineteen patients had complete follow-up. Fasting glucose, HbA1c (glycated hemoglobin), markers for nitrosative, carbonyl, and oxidative stress (nitrotyrosine, carboxylated-lysine (CML), methylglyoxal, oxidized low-density-lipoprotein (oxLDL)) as well as Neuropeptid Y and Neurokinin A were investigated over 12 months. Neuropathy was assessed using the Neuropathy Deficit Score (NDS).

RESULTS

The preoperative NDS improved within twelve months (5.1 ± 0.6 to 2.6 ± 0.4, P = .010). Fasting glucose and HbA1c also improved compared to preoperative values (201.1 ± 16.6 mg/dL to 128 ± 8.7 mg/dL, P = .004 and 8.5 ± 0.3% (53 ± 3.3 mmol/mol) to 7 ± 0.3% (67 ± 3.3 mmol/mol), P = .001, respectively). Nitrotyrosine, CML, and methylglyoxal all 3 decreased postoperatively (1067.3 ± 266.9 nM to 355.8 ± 36.4 nM, P = .003; 257.1 ± 10.2 ng/ml to 215.3 ± 18.3 ng/ml, P = .039; 402.3 ± 3.9 nM to 163.4 ± 10.3 nM, P = .002). OxLDL remained unchanged. Fasting glucose and HbA1c did not correlate with improved neuropathy. The decrease in nitrotyrosine correlated with improvement in the NDS after 6 and twelve months (r = .9, P < .001 and r = .68, P = .03). The decrease in methylglyoxal after 6 months correlated with decrease in NDS after twelve months (r = 0.897, P = .003).

CONCLUSION

RYGB seems to improve oxidative, nitrosative and carbonyl stress, known to have a causal role in diabetic neuropathy.

Could the improvement of obesity-related co-morbidities depend on modified gut hormones secretion?

Obesity and its associated diseases are a worldwide epidemic disease. Usual weight loss cures - as diets, physical activity, behavior therapy and pharmacotherapy - have been continuously implemented but still have relatively poor long-term success and mainly scarce adherence. Bariatric surgery is to date the most effective long term treatment for morbid obesity and it has been proven to reduce obesity-related co-morbidities, among them nonalcoholic fatty liver disease, and mortality. This article summarizes such variations in gut hormones following the current metabolic surgery procedures. The profile of gut hormonal changes after bariatric surgery represents a strategy for the individuation of the most performing surgical procedures to achieve clinical results. About this topic, experts suggest that the individuation of the crosslink among the gut hormones, microbiome, the obesity and the bariatric surgery could lead to new and more specific therapeutic interventions for severe obesity and its co-morbidities, also non surgical.

Glycemic variability and oxidative stress: a link between diabetes and cardiovascular disease?

Diabetes is associated with a two to three-fold increase in risk of cardiovascular disease. However, intensive glucose-lowering therapy aiming at reducing HbA1c to a near-normal level failed to suppress cardiovascular events in recent randomized controlled trials. HbA1c reflects average glucose level rather than glycemic variability. In in vivo and in vitro studies, glycemic variability has been shown to be associated with greater reactive oxygen species production and vascular damage, compared to chronic hyperglycemia. These findings suggest that management of glycemic variability may reduce cardiovascular disease in patients with diabetes; however, clinical studies have shown conflicting results. This review summarizes the current knowledge on glycemic variability and oxidative stress, and discusses the clinical implications.

Long term quality of life after laparoscopic antireflux surgery for the elderly

BACKGROUND

Studies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life.

METHODS

Patients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

RESULTS

Forty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG).

CONCLUSIONS

In conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.

Long term quality of life after laparoscopic antireflux surgery for the elderly

Background

Studies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life.

Methods

Patients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

Results

Forty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG).

There were 114 (36.6%) patients who filled out the SF36 questionnaire (98 in the younger group, rate: 37.4%; 16 in the elderly group, rate: 32.6%) pre- and post-operatively. There was no significant difference between the two age groups regarding preoperative PCS ( 45.6 ± 7.8 in YG vs. 44.2 ± 8.2 in EG; P = 0.51) and MCS ( 48.1 ± 10.7 in YG vs. 46.9 ± 9.2 in EG; P = 0.67). There was no significant difference between the two age groups regarding postoperative PCS (49.8 ± 11.9 in YG and 48.2 ± 9.5 in EG ; P = 0.61 and MCS (48.4 ± 10.7 in YG vs. 50.1 ± 6.9 in EG; P = 0.54).

Conclusions

In conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.

Mechanisms responsible for excess weight loss after bariatric surgery

Obesity has increased alarmingly in the United States and is increasing in many countries of the world. Because obesity is an important risk factor for type 2 diabetes and other chronic diseases, it is important to develop approaches to counter the rapid increase in adiposity. One approach is bariatric surgery, the most successful clinical intervention known for treating obesity. Surgery can result in impressive weight loss and improvement of obesity-related comorbidities. Yet the mechanisms responsible for this remarkable effect of surgery remain controversial. It is now clear that caloric restriction, per se, does not explain all the reduction in stored fat mass after surgery. A number of gastrointestinal hormones, including glucagon-like peptide (GLP)-1, peptide YY, oxyntomodulin, GLP-2, glucose-dependent insulinotropic polypeptide, ghrelin, and others, can play roles in energy homeostasis and could be involved in bariatric-surgery-related weight loss and weight loss maintenance. Vagal innervation may play a role. In addition, there may be other yet-uncharacterized factors that could participate. This review discusses the possible roles of these hormonal mechanisms in various types of bariatric surgery to help elucidate some of the potential mechanisms at play in short-term and long-term post-bariatric surgery weight loss. Understanding such mechanisms could lead to new and efficacious means to control or even reduce the epidemic of obesity.

Normal reference range for mean tissue glucose and glycemic variability derived from continuous glucose monitoring for subjects without diabetes in different ethnic groups

BACKGROUND

Glycemic variability has been proposed as a contributing factor in the development of diabetes complications. Multiple measures exist to calculate the magnitude of glycemic variability, but normative ranges for subjects without diabetes have not been described. For treatment targets and clinical research we present normative ranges for published measures of glycemic variability.

METHODS

Seventy-eight subjects without diabetes having a fasting plasma glucose of <120 mg/dL (6.7 mmol/L) underwent up to 72 h of continuous glucose monitoring (CGM) with a Medtronic Minimed (Northridge, CA) CGMS(®) Gold device. Glycemic variability was calculated using EasyGV(©) software (available free for non-commercial use at www.easygv.co.uk ), a custom program that calculates the SD, M-value, mean amplitude of glycemic excursions (MAGE), average daily risk ratio (ADRR), Lability Index (LI), J-Index, Low Blood Glucose Index (LBGI), High Blood Glucose Index (HBGI), continuous overlapping net glycemic action (CONGA), mean of daily differences (MODD), Glycemic Risk Assessment in Diabetes Equation (GRADE), and mean absolute glucose (MAG).

RESULTS

Eight CGM traces were excluded because there were inadequate data. From the remaining 70 traces, normative reference ranges (mean±2 SD) for glycemic variability were calculated: SD, 0-3.0; CONGA, 3.6-5.5; LI, 0.0-4.7; J-Index, 4.7-23.6; LBGI, 0.0-6.9; HBGI, 0.0-7.7; GRADE, 0.0-4.7; MODD, 0.0-3.5; MAGE-CGM, 0.0-2.8; ADDR, 0.0-8.7; M-value, 0.0-12.5; and MAG, 0.5-2.2.

CONCLUSIONS

We present normative ranges for measures of glycemic variability in adult subjects without diabetes for use in clinical care and academic research.

Reduction of 8-iso-prostaglandin F2α in the first week after Roux-en-Y gastric bypass surgery

Obesity is associated with increased markers of oxidative stress. We examined whether oxidative stress is reduced within the first week after Roux-en-Y gastric bypass (RYGB) surgery and could be related to changes in adipose tissue depots. The reactive oxygen species (ROS) marker 8-iso-prostaglandin F2α (8-iso-PGF2α) and activity of antioxidant glutathione peroxidases (GPX) in plasma were compared before and ~1 week after RYGB. The effects of RYGB on subcutaneous adipose tissue and interstitial fluid 8-iso-PGF2α levels and subcutaneous adipose tissue expression of GPX-3 were also assessed. Levels of 8-iso-PGF2α in subcutaneous and visceral adipose tissue were determined. Plasma 8-iso-PGF2α levels decreased (122 ± 75 to 56 ± 15 pg/ml, P = 0.001) and GPX activity increased (84 ± 18 to 108 ± 25 nmol/min/ml, P = 0.003) in the first week post-RYGB. RYGB also resulted in reductions of 8-iso-PGF2α in subcutaneous adipose tissue (1,742 ± 931 to 1,132 ± 420 pg/g fat, P = 0.046) and interstitial fluid (348 ± 118 to 221 ± 83 pg/ml, P = 0.046) that were comparable to plasma (26-33%, P = 0.74). Adipose GPX-3 expression was increased (6.7 ± 4.7-fold, P = 0.004) in the first postoperative week. The improvements in oxidative stress occurred with minimal weight loss (2.4 ± 3.4%, P = 0.031) and elevations in plasma interleukin-6 (18.0 ± 46.8 to 28.0 ± 58.9 pg/ml, P = 0.004). Subcutaneous and visceral adipose tissues express comparable 8-iso-PGF2α levels (1,204 ± 470 and 1,331 ± 264 pg/g fat, respectively; P = 0.34). These data suggest that RYGB affects adipose tissue leading to the restoration of adipose redox balance within the first postoperative week and that plasma 8-iso-PGF2α is primarily derived from subcutaneous adipose tissue.

Normal reference range for mean tissue glucose and glycemic variability derived from continuous glucose monitoring for subjects without diabetes in different ethnic groups

BACKGROUND

Glycemic variability has been proposed as a contributing factor in the development of diabetes complications. Multiple measures exist to calculate the magnitude of glycemic variability, but normative ranges for subjects without diabetes have not been described. For treatment targets and clinical research we present normative ranges for published measures of glycemic variability.

METHODS

Seventy-eight subjects without diabetes having a fasting plasma glucose of <120 mg/dL (6.7 mmol/L) underwent up to 72 h of continuous glucose monitoring (CGM) with a Medtronic Minimed (Northridge, CA) CGMS(®) Gold device. Glycemic variability was calculated using EasyGV(©) software (available free for non-commercial use at www.easygv.co.uk ), a custom program that calculates the SD, M-value, mean amplitude of glycemic excursions (MAGE), average daily risk ratio (ADRR), Lability Index (LI), J-Index, Low Blood Glucose Index (LBGI), High Blood Glucose Index (HBGI), continuous overlapping net glycemic action (CONGA), mean of daily differences (MODD), Glycemic Risk Assessment in Diabetes Equation (GRADE), and mean absolute glucose (MAG).

RESULTS

Eight CGM traces were excluded because there were inadequate data. From the remaining 70 traces, normative reference ranges (mean±2 SD) for glycemic variability were calculated: SD, 0-3.0; CONGA, 3.6-5.5; LI, 0.0-4.7; J-Index, 4.7-23.6; LBGI, 0.0-6.9; HBGI, 0.0-7.7; GRADE, 0.0-4.7; MODD, 0.0-3.5; MAGE-CGM, 0.0-2.8; ADDR, 0.0-8.7; M-value, 0.0-12.5; and MAG, 0.5-2.2.

CONCLUSIONS

We present normative ranges for measures of glycemic variability in adult subjects without diabetes for use in clinical care and academic research.

High glycemic variability assessed by continuous glucose monitoring after surgical treatment of obesity by gastric bypass

BACKGROUND

Obesity surgery elicits complex changes in glucose metabolism that are difficult to observe with discontinuous glucose measurements. We aimed to evaluate glucose variability after gastric bypass by continuous glucose monitoring (CGM) in a real-life setting.

METHODS

CGM was performed for 4.2 ± 1.3 days in three groups of 10 subjects each: patients who had undergone gastric bypass and who were referred for postprandial symptoms compatible with mild hypoglycemia, nonoperated diabetes controls, and healthy controls.

RESULTS

The maximum interstitial glucose (IG), SD of IG values, and mean amplitude of glucose excursions (MAGE) were significantly higher in operated patients and in diabetes controls than in healthy controls. The time to the postprandial peak IG was significantly shorter in operated patients (42.8 ± 6.0 min) than in diabetes controls (82.2 ± 11.1 min, P = 0.0002), as were the rates of glucose increase to the peak (2.4 ± 1.6 vs. 1.2 ± 0.3 mg/mL/min; P = 0.041). True hypoglycemia (glucose <60 mg/dL) was rare: the symptoms were probably more related to the speed of IG decrease than to the glucose level achieved. Half of the operated patients, mostly those with a diabetes background before surgery, had postprandial glucose concentrations above 200 mg/dL (maximum IG, 306 ± 59 mg/dL), in contrast to the normal glucose concentrations in the fasting state and 2 h postmeal.

CONCLUSIONS

Glucose variability is exaggerated after gastric bypass, combining unusually high and early hyperglycemic peaks and rapid IG decreases. This might account for postprandial symptoms mimicking hypoglycemia but often seen without true hypoglycemia. Early postprandial hyperglycemia might be underestimated if glucose measurements are done 2 h postmeal.

Relationships between daily acute glucose fluctuations and cognitive performance among aged type 2 diabetic patients

OBJECTIVE

The mean amplitude of glycemic excursions (MAGE) is a significant determinant of overall metabolic control as well as increased risk for diabetes complications. Older individuals with type 2 diabetes are more likely to have moderate cognitive deficits and structural changes in brain tissue. Considering that poor metabolic control is considered a deranging factor for cognitive performance in diabetic patients, we evaluated whether the contributions of MAGE to cognitive status in older patients with type 2 diabetes were independent from the main markers of glycemic control, such as sustained chronic hyperglycemia (A1C), postprandial glycemia (PPG), and fasting plasma glucose (FPG).

RESEARCH DESIGN AND METHODS

In 121 older patients with type 2 diabetes, 48-h continuous subcutaneous glucose monitoring (CSGM) were assessed. MAGE and PPG were evaluated during CSGM. The relationship of MAGE to performance on cognitive tests was assessed, with adjustment for age, glycemic control markers, and other determinants of cognitive status. The cognitive tests were a composite score of executive and attention functioning and the Mini Mental Status Examination (MMSE).

RESULTS

MAGE was significantly correlated with MMSE (r = 0.83; P < 0.001) and with cognition composite score (r = 0.68; P < 0.001). Moreover, MAGE was associated with the MMSE (P < 0.001) and cognition composite score (P < 0.001) independently of age, sex, BMI, waist-to-hip (WHR) ratio, drug intake, physical activity, mean arterial blood pressure, FPG, PPG, and A1C.

CONCLUSIONS

MAGE during a daily period was associated with an impairment of cognitive functioning independent of A1C, FPG, and PPG. The present data suggest that interventional trials in older patients with type 2 diabetes should target not only A1C, PPG, and FPG but also daily acute glucose swings.