Incidence and Clinical Features of Diabetic Ketoacidosis After Bariatric and Metabolic Surgery

The emergence of obesity in type 1 diabetes

Obesity, a chronic low-grade inflammatory disease represented by multifactorial metabolic dysfunctions, is a significant global health threat for adults and children. The once-held belief that type 1 diabetes is a disease of people who are lean no longer holds. The mounting epidemiological data now establishes the connection between type 1 diabetes and the subsequent development of obesity, or vice versa. Beyond the consequences of the influx of an obesogenic environment, type 1 diabetes-specific biopsychosocial burden further exacerbates obesity. In the course of obesity management discussions, recurring challenges surfaced. The interplay between weight gain and escalating insulin dependence creates a vicious cycle from which patients struggle to break free. In the absence of weight management guidelines and regulatory approval for this population, healthcare professionals must navigate the delicate balance between benefits and risks. The gravity of this circumstance highlights the importance of bringing these topics to the forefront. In this Review, we discuss the changing trends and the biopsychosocial aspects of the intersection between type 1 diabetes and obesity. We highlight the evidence supporting the therapeutic means (i.e., exercise therapy, nutritional therapy, adjunct pharmacotherapy, and bariatric surgery) and directions for establishing a more robust and safer evidence-based approach.

Use of SGLT2 inhibitors after bariatric/metabolic surgery: Risk/benefit balance

Bariatric/metabolic surgery and sodium-glucose cotransporter 2 inhibitors (SGLT2is) are becoming increasingly popular for the management of overweight/obese patients with type 2 diabetes mellitus (T2DM). Consequently, the chance that a patient undergoing bariatric/metabolic surgery is also treated with an SGLT2i would be rather common in clinical practice. Both risks and benefits have been reported. On the one hand, several cases of euglycemic diabetic ketoacidosis have been reported within the few days/weeks after bariatric/metabolic surgery. The causes are diverse but a drastic reduction in caloric (carbohydrate) intake most probably plays a crucial role. Thus, SGLT2is should be stopped a few days (and even more if a pre-operative restricted diet is prescribed to reduce liver volume) before the intervention and reintroduced only when the caloric (carbohydrate) intake is sufficient. On the other hand, SGLT2is may exert a favorable effect to reduce the risk of postprandial hypoglycemia, a complication reported among patients who have been treated with bariatric/metabolic surgery. An increased hepatic glucose production and a reduced production of interleukin-1β have been proposed as possible underlying mechanisms for this protective effect. Finally, whether SGLT2is could prolong diabetes remission following surgery and improve the prognosis of patients with T2DM who benefit from bariatric/metabolic surgery remains to be investigated.

High preoperative HbA1c does not affect early or late complication rates after bariatric surgery

BACKGROUND

Preoperative HbA1c has been associated with an increased incidence of postoperative morbidity and mortality after abdominal and cardiovascular surgery. The literature on bariatric surgery is inconclusive and guidelines recommend postponement of surgery when HbA1c is above an arbitrary threshold (≥ 8.5%). In this study, we sought to understand the impact of preoperative HbA1c on early and late postoperative complications.

METHODS

We performed a retrospective analysis of prospectively collected data on obese patients with diabetes who underwent laparoscopic bariatric surgery. Patients were categorized into three groups according to their preoperative HbA1c level: < 6.5% (group 1), 6.5-8.4% (group 2) and ≥ 8.5% (group 3). Primary outcomes were early and late postoperative complications (< and > 30 days, respectively) that were differentiated based on severity (major/minor). Secondary outcomes were length of stay (LOS), duration of surgery, and rate of readmission.

RESULTS

In total, 6798 patients underwent laparoscopic bariatric surgery from 2006 to 2016, of which 1021 (15%) patients had Type 2 Diabetes (T2D). Complete data with a median follow-up of 45 months (3-120) were available for 914 patients with HbA1c < 6.5% (n = 227, 24.9%), 6.5-8.4% (n = 532, 58.5%) and ≥ 8.5% (n = 152, 16.6%). Early major surgical complication rate was similar across the groups ranging from 2.6 to 3.3%. No associations between high preoperative HbA1c and late complications-medical as well as surgical-was observed. Groups 2 and 3 had statistically significant more pronounced inflammatory status. LOS (1.8-1.9 days), readmission rates (1.7-2.0%) and surgical time was similar across the three groups.

CONCLUSION

Elevated HbA1c is not associated with more early or late postoperative complications, longer LOS, longer surgical time or higher rates of readmission.

Safety of body contouring surgery in an aging patient population

The fastest-growing age group undergoing cosmetic procedures are those over age 60, i.e. the aging patient group. While advanced age is a known predictor for increased surgical complications, the effects of age on complications in specific plastic procedures have yet to be thoroughly investigated. To determine the relationship between increased age and risk of surgical complications following body contouring procedures, specifically: abdominoplasty, brachioplasty, mastopexy, bilateral reduction, and thigh lift. A retrospective analysis of all patients undergoing body contouring procedures of the categories mentioned above between 2000-2018 at a tertiary university medical center. Patients were divided into two age groups: those below and those above, age 60. Data analysis included: demographics, underlying medical conditions, procedure type, and occurrence of postoperative complications (according to the Clavien-Dindo classification system). 803 body contouring procedures were identified, with 12% performed on the aging population. Aging patients had more underlying medical conditions than the younger ones. While the distribution of procedure type was similar in both groups, mastopexy was more common in aging patients. Of the 107 procedures identified as having complications, 37 were classified as grade I, 38 as grade II, and 32 as grade III. As a categorical variable, no relationship was found between the age of the patients and an increased risk of postoperative complications (age cut-off as 60). However, as a continuous variable, increased age did increase the overall risk of postoperative complications, although no optimal age as a cut-off point was identified. In multivariant analysis, diabetes mellitus with abdominoplasty was identified as a risk factor for postoperative complications. Conclusions: When undergoing body contouring procedures, we found that patients over the age of 60 are not at increased risk for postoperative complications than those under that age. Although age as a continuous variable was found to increase the overall postoperative complications, no optimal age could be defined as a cut-off point.

Potential Clinical Applications for Continuous Ketone Monitoring in the Hospitalized Patient with Diabetes

PURPOSE OF REVIEW

In this review, the authors discuss potential clinical applications for continuous ketone monitoring (CKM) in a broad continuum of clinical settings from pre-hospital care and the emergency department to acute inpatient management and post-discharge follow-up.

RECENT FINDINGS

Though in its early stages, the concept of a novel continuous ketone sensing technology exerts great potential for use in the detection and hospital management of DKA, namely to overcome diagnostic barriers associated with ketoacidosis in patients with diabetes and obtain real-time BOHB levels, which may be useful in understanding both patients' response to treatment and DKA trajectory. Peri- and intra-operative use of CKM technology can potentially be applied in a number of urgent and elective surgical procedures frequently underwent by patients with diabetes and in the observation of patients during peri-operative fasting. In transitional care management, CKM technology could potentially facilitate patients' safe transition through levels of care, following hospital discharge from a DKA episode. This evaluation of the literature presents the potential advantages of adopting CKM and integrating this technology into the care algorithm of patients at risk for ketoacidosis.

Current Status of Metabolic/Bariatric Surgery in Type 1 Diabetes Mellitus: an Updated Systematic Review and Meta-analysis

This systematic review and meta-analysis intend to evaluate the efficacy of metabolic/bariatric surgeries (MBS) in patients with type-1 diabetes mellitus. A systematic literature search and meta-analysis were performed in electronic databases up to July 2021. In total, 27 primary studies comprising 648 subjects were included in this systematic review and meta-analysis. Patients had a mean age of 38.0 ± 7.3 years. Preoperative mean BMI was 42.6 ± 4.7 kg/m² and 29.4 ± 4.7 kg/m² after surgery, respectively. Following bariatric surgeries in patients with type 1 diabetes mellitus, insulin (unit/day) decreased by a weighted mean difference (WMD) of - 10.59. Also, insulin (unit/kg/day) decreased by a WMD of - 0.2, and HbA1C decreased by a WMD of - 0.71, showing MBS acceptable and durable effects of bariatric surgical procedures.

Measuring ketone bodies for the monitoring of pathologic and therapeutic ketosis

BACKGROUND

The ketone bodies β-hydroxybutyrate (BOHB) and acetone are generated as a byproduct of the fat metabolism process. In healthy individuals, ketone body levels are ∼0.1 mM for BOHB and ∼1 part per million for breath acetone (BrAce). These levels can increase dramatically as a consequence of a disease process or when used therapeutically for disease treatment. For example, increased ketone body concentration during weight loss is an indication of elevated fat metabolism. Ketone body measurement is relatively inexpensive and can provide metabolic insights to help guide disease management and optimize weight loss.

METHODS

This review of the literature provides metabolic mechanisms and typical concentration ranges of ketone bodies, which can give new insights into these conditions and rationale for measuring ketone bodies.

RESULTS

Diseases such as heart failure and ketoacidosis can affect caloric intake and macronutrient management, which can elevate BOHB 30-fold and BrAce 1000-fold. Other diseases associated with obesity, such as brain dysfunction, cancer, and diabetes, may cause dysfunction because of an inability to use glucose, excessive reliance on glucose, or poor insulin signaling. Elevating ketone body concentrations (e.g., nutritional ketosis) may improve these conditions by forcing utilization of ketone bodies, in place of glucose, for fuel. During weight loss, monitoring ketone body concentration can demonstrate program compliance and can be used to optimize the weight-loss plan.

CONCLUSIONS

The role of ketone bodies in states of pathologic and therapeutic ketosis indicates that accurate measurement and monitoring of BOHB or BrAce will likely improve disease management. Bariatric surgery is examined as a case study for monitoring both types of ketosis.

Bariatric surgery in the treatment of patients with obesity and type 1 diabetes: A retrospective study of clinical data

AIM

To evaluate the effectiveness and safety of bariatric surgery in patients with coexisting type 1 diabetes and obesity who choose to undergo bariatric surgery for weight management.

MATERIALS AND METHODS

We conducted a retrospective, longitudinal review of the clinical data of patients with type 1 diabetes, followed up at our centre after bariatric surgery had been performed elsewhere.

RESULTS

Sixty-one patients were included, of whom 51% were women, and 57 (93%) were Emirati Arab, three (5%) were other Arab, and one (2%) was White in ethnic origin. The mean age at surgery was 31 years. A total of 42 patients (69%) underwent sleeve gastrectomy, 17 (28%) gastric bypass, and two (3%) gastric banding. In 48 patients with complete follow-up data, improvements were observed at 12 months in the median (interquartile range [IQR]) values for body mass index (BMI; 38.5 [34.9-40.9] to 26.1 [24.2-29.6] kg/m² , P <0.001), glycated haemoglobin concentration (8.6 [7.8-9.2]% to 7.8 [7.2-8.5]%; P <0.001), daily insulin dose (1.0 [0.7-1.2] to 0.8 [0.6-0.9] units/kg/d; P <0.001), systolic blood pressure (127 [116-136] to 116 [110-120] mmHg; P <0.001), total cholesterol: high-density lipoprotein cholesterol ratio (3.4 [2.9-4.3] to 3.0 [2.6-3.5]; P <0.001), and albuminuria. In 32 patients followed up at 3 years, the median (IQR) reduction in BMI was 10.4 (5.9-11.7) kg/m² , 50% reduced or stopped antihypertensive medication and 58% reduced or stopped lipid-modifying medication. Three patients each reported a single episode of diabetic ketoacidosis; in one case this was due to cessation of insulin treatment.

CONCLUSIONS

In our cohort of patients with obesity and type 1 diabetes, bariatric surgery led to significant improvements in weight and cardiometabolic variables, with modest improvements in glycaemia. Few adverse events were reported.

Clinical significance of diabetes control before metabolic surgery

BACKGROUND

Even though observational studies have suggested that poor preoperative diabetes control increases risk after major abdominal surgery, it is unclear whether this effect is seen in metabolic surgery patients.

OBJECTIVES

To determine whether poor preoperative diabetes control is associated with worse outcomes in patients with obesity and diabetes undergoing metabolic surgery.

SETTING

Metabolic and Bariatric Surgery Quality Improvement Project (MBSAQIP) database.

METHODS

Using the MBSAQIP 2017 and 2018 database and preoperative glycated hemoglobin (HbA1C) as a diabetes control surrogate, we examined the association between diabetes control and major outcomes of primary laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) in patients with diabetes and obesity. Multivariate logistic regression modeling examined five 30-day postoperative outcomes: composite serious complications (composite of 10 adverse events), composite infection (composite of 7 infectious complications), length of stay >5 days, reoperation, and readmission. Models were adjusted for multiple covariates.

RESULTS

In total, 26,674 patients with HbA1C data available within 30 days before metabolic surgery were included in the primary analysis and 35,884 patients with HbA1C data within 90 days before surgery were included in the sensitivity analysis. The mean body mass index (BMI) and preoperative HbA1C were 45.6 ± 8.2 kg/m² and 8.2 ± 2.7%, respectively. The incidence of 30-day postoperative infections and serious complications were 1.62% and 1.35%, respectively. Neither primary analysis nor sensitivity analysis demonstrated any association between higher HbA1C and worsening of 5 primary outcomes of interest. The odds ratio of an overall effect for SG was 1.01 (95% CI .98-1.03; P = .58) and for RYGB was .99 (95% CI .96-1.02; P = .41).

CONCLUSION

Suboptimal preoperative diabetes control is not associated with increased adverse events and should not delay metabolic surgery, as metabolic surgery is generally a safe procedure and intrinsically improves diabetes control.

Post-Operative Euglycemic Diabetic Ketoacidosis in a Patient With SGLT-2 Inhibitor Use and Recent Sleeve Gastrectomy

A 51-year-old woman with type 2 diabetes mellitus developed euglycemic diabetic ketoacidosis (euDKA) in the post-operative setting after robotic-assisted sleeve gastrectomy. She developed tachycardia on post-operative day (POD) 1 before developing altered mental status and tachypnea on POD 2. The diagnosis was ultimately made by discovering ketonuria in the setting of anion gap metabolic acidosis despite repeatedly normal blood glucose levels. Pre-operatively, her blood glucose levels were managed with sodium-glucose co-transporter-2 (SGLT-2) inhibitor-containing combination pill, Invokamet®, as well as basal-bolus insulin regimen consisting of aspart (NovoLog®) and glargine-lixisenatide (Soliqua®). SLGT-2 inhibitors have been associated with an increased risk of euDKA, particularly in the context of severe bodily stressors such as surgery. EuDKA is a difficult diagnosis to make because of the lack of characteristic severe hyperglycemia that is typical of DKA. Clinicians should be mindful of euDKA in the post-operative setting of diabetic patients, particularly for those on SGLT-2 inhibitors.

Obesity in Patients with Type 1 Diabetes: Links, Risks and Management Challenges

Obesity affects large numbers of patients with type 1 diabetes (T1D) across their lifetime, with rates ranging between 2.8% and 37.1%. Patients with T1D and obesity are characterized by the presence of insulin resistance, of high insulin requirements, have a greater cardiometabolic risk and an enhanced risk of developing chronic complications when compared to normal-weight persons with T1D. Dual treatment of obesity and T1D is challenging and no specific guidelines for improving outcomes of both glycemic control and weight management have been established for this population. Nevertheless, although evidence is scarce, a comprehensive approach based on a balanced hypocaloric diet, physical activity and cognitive behavioral therapy by a multidisciplinary team, expert in both obesity and diabetes, remains as the best clinical practice. However, weight loss responses with lifestyle changes alone are limited, so in the "roadmap" of the treatment of obesity in T1D, it will be helpful to include anti-obesity pharmacotherapy despite at present there is a lack of evidence since T1D patients have been excluded from anti-obesity drug clinical trials. In case of severe obesity, bariatric surgery has proven to be of benefit in obtaining a substantial and long-term weight loss and reduction in cardiovascular risk. The near future looks promising with the development of new and more effective anti-obesity treatments and strategies to improve insulin resistance and oxidative stress. Advances in precision medicine may help individualize and optimize the medical management and care of these patients. This review, by gathering current evidence, highlights the need of solid knowledge in all facets of the treatment of patients with obesity and T1D that can only be obtained through high quality well-designed studies.

SGLT-2 Inhibitors-a Culprit of Diabetic Ketoacidosis Postbariatric Surgery

Sodium-glucose cotransporter-2 SGLT2 inhibitors are antihyperglycemic drugs that are currently being recommended as second-line therapy for patients with diabetes mellitus. They have grown increasingly popular over recent years, as they have been shown to have some protective effects on the heart and kidneys, both organ systems that diabetes mellitus has shown to have deleterious effect on over time. Despite their growing popularity, they have been found to increase the risk of euglycemic diabetic ketoacidosis (DKA). There is an increasing body of literature detailing cases of euglycemic DKA after bariatric surgery. We present a case series of three cases of euglycemic DKA postbariatric surgery in patients with an underlying history of type 2 diabetes mellitus, who were being treated with SGLT2 inhibitors prior to the surgery. All three patients reported to the emergency room with signs, symptoms, and clinical findings of euglycemic DKA. The AACE recommends SGLT2 inhibitors to be discontinued at least 24 hours prior to surgery and resumed when a patient resumes a normal diet. Our patients presented with euglycemic DKA after bariatric surgery, and we recommend more research should be done targeted at the prolonged postoperative course of patients on SGLT-2 inhibitors and into creating specific guidelines for their use after bariatric surgery.

Euglycemic Diabetic Ketoacidosis With Sodium-Glucose Cotransporter-2 Inhibitor Use Post-Bariatric Surgery: A Brief Review of the Literature

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are antihyperglycemic drugs that are currently being recommended as second-line therapy for patients with diabetes mellitus. SGLT-2 Inhibitors function by inhibiting renal cotransporters, which reduces the reabsorption of glucose in the kidney, ultimately decreasing the concentration of glucose in the body. They have gained popularity in recent years due to their protective effects on the heart and kidneys - both organ systems that diabetes mellitus has shown to have a deleterious effect on. However, despite their growing fame, they have been found to increase the risk of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is particularly dangerous as there is a chance that it can be missed by clinicians due to glucose levels generally being less than 200 mg/dL. There is an increasing body of literature detailing cases of euglycemic DKA after bariatric surgery. We present a brief review of the literature regarding this important side effect of SGLT-2 inhibitors seen in patients after bariatric surgery.

Bariatric Surgery and Type 1 Diabetes: Unanswered Questions

In recent decades there has been an alarming increase in the prevalence of obesity in patients with type 1 diabetes leading to the development of insulin resistance and cardiometabolic complications, with mechanisms poorly clarified. While bariatric surgery has long been considered an effective treatment option for patients with type 2 diabetes, the evidence regarding its benefits on weight loss and the prevention of complications in T1DM patients is scarce, with controversial outcomes. Bariatric surgery has been associated with a significant reduction in daily insulin requirement, along with a considerable reduction in body mass index, results which were sustained in the long term. Furthermore, studies suggest that bariatric surgery in type 1 diabetes results in the improvement of comorbidities related to obesity including hypertension and dyslipidemia. However, regarding glycemic control, the reduction of mean glycosylated hemoglobin was modest or statistically insignificant in most studies. The reasons for these results are yet to be elucidated; possible explanations include preservation of beta cell mass and increased residual function post-surgery, improvement in insulin action, altered GLP-1 function, timing of surgery, and association with residual islet cell mass. A number of concerns regarding safety issues have arisen due to the reporting of peri-operative and post-operative adverse events. The most significant complications are metabolic and include diabetic ketoacidosis, severe hypoglycemia and glucose fluctuations. Further prospective clinical studies are required to provide evidence for the effect of bariatric surgery on T1DM patients. The results may offer a better knowledge for the selection of people living with diabetes who will benefit more from a metabolic surgery.

Management of Diabetes in Patients Undergoing Bariatric Surgery

PURPOSE OF REVIEW

The number of bariatric surgeries for patients with type 1 or type 2 diabetes continues to grow. Clinicians are challenged to choose therapies that reach glycemic targets without inducing adverse effects in post-bariatric patients without published guidelines. This review evaluates data supporting the best strategies for diabetes management in patients undergoing bariatric surgery.

RECENT FINDINGS

Though few clinical trials have evaluated the safety and effectiveness of different glucose-lowering therapies following bariatric surgery, remission of diabetes or reduced medications is an established benefit of bariatric surgery. Adverse events including diabetic ketoacidosis in post-bariatric patients on sodium-glucose co-transporter 2 (SGLT2) inhibitors or inadequate insulin have been reported in patient's with both type 1 and type 2 diabetes. Metformin, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, SGLT2 inhibitors, insulin, and sulfonylureas have been used successfully in the perioperative period for other surgeries and guidelines recommend adjusting the doses of these medications especially in the perioperative period. Clinicians should favor weight-neutral or weight-loss promoting therapies in post-bariatric surgery patients such as medical nutrition therapy, metformin, GLP-1 agonists, SGLT2 inhibitors, and DPP-4 inhibitors.

Diabetes management before, during, and after bariatric and metabolic surgery

Metabolic surgery is unrivaled by other therapeutic modalities due to its ability to foster diabetes remission. Metabolic surgery is an integral therapeutic modality in obese and morbidly obese populations because pharmacological and behavioral therapy often fail to effectively manage type II diabetes. However, given the invasiveness of the metabolic surgery relative to behavioral therapy and the need to conform to preparatory and discharge guidelines, patients must adhere to strict nutritional and diabetes management protocols. Also, the pharmacological regimen that is instituted upon discharge is distinct from the preoperative regimen. Oftentimes, the dose for insulin and oral medications are significantly decreased or withdrawn. As time elapses and depending on several factors (e.g., exercise adherence), diabetes control becomes tenuous in a small portion of the patients because there is weight regain and on-going beta cell failure. At this time interval, intensification of diabetes therapy becomes prudent. Indeed, pharmacotherapy from the preoperative to the postoperative phase is labile and may be complex. Therefore, by discussing pharmacology options during the preoperative, perioperative, and postoperative period, the goal is to guide clinician-driven care.

Diabetic Ketoacidosis Post Bariatric Surgery

In patients with type 2 diabetes, bariatric surgery can lead to significant improvements in glycemic control and diabetes remission. We present a case of a Hispanic female with type 2 diabetes phenotype who underwent bariatric surgery and post-operatively stopped her insulin therapy due to multiple reasons, including decreased oral intake and concern for hypoglycemia. Ultimately, she developed diabetic ketoacidosis. She does not fit into the classical type 2 diabetes or type 1 diabetes definition but into the heterogeneous subgroup of diabetes called ketosis-prone diabetes.

Perioperative Management of Patients with Diabetes

Hyperglycemia has long been recognized to have detrimental effects on postoperative outcomes in patients undergoing surgery. The manifestations of uncontrolled diabetes are manifold and can include risk of hyperglycemic crises, postoperative infection, poor wound healing, and increased mortality. There is substantial literature supporting the role of diligent glucose control in the prevention of adverse surgical outcomes, but considerable debate remains as to the optimal glucose targets. Hence, most organizations advocate the avoidance of hypoglycemia while striving for adequate glucose control in the perioperative period. These objectives can be accomplished with careful preoperative evaluation, clear patient instructions the day of surgery, frequent blood glucose monitoring during the perioperative period, and use of effective strategies for insulin initiation and titration. This article highlights the major issues concerning patients with diabetes undergoing surgery and reviews the management recommendations put forth by general consensus guidelines and expert opinion.

Bariatric Surgery in Obese Patients With Type 1 Diabetes

OBJECTIVE

There is a paucity of data on the impact of bariatric surgery in type 1 diabetes (T1D). The aim of this review was to quantify the overall effects of bariatric surgery in obese patients with T1D.

METHODS

We searched PubMed, Scopus, ISI Web of Knowledge, and Google Scholar from their inception to December 2015 to identify all relevant studies of bariatric surgery in adult obese patients with T1D.

RESULTS

The review included 17 studies with 107 individuals, including 10 case series and 7 case reports. Overall, the dominant procedure was gastric bypass (n = 70; 65%). All studies reported a significant reduction in excess weight. A significant reduction in weight-adjusted daily insulin requirements was shown in all case series except one. Pooled mean ± SD of pre- and postoperative glycated hemoglobin (HbA1c) for the entire cohort with available data (n = 96) was 8.4 ± 1.3% and 7.9 ± 1.1%, respectively (P = 0.01). In addition to common postoperative complications, profound glycemic changes (diabetic ketoacidosis and hypoglycemia) and gastrointestinal dysmotility symptoms (prolonged ileus and acute gastric remnant dilation) have been reported. No surgical mortality was reported.

CONCLUSIONS

Bariatric surgery leads to significant weight loss in severely obese patients with T1D and results in a significant improvement in insulin requirements and glycemic status. The favorable metabolic effects of bariatric surgery may facilitate medical management of and cardiovascular risk reduction in T1D in the setting of severe obesity. Diabetic ketoacidosis and hypoglycemia are potentially serious complications. Short-term results of bariatric surgery in patients with T1D are encouraging, but larger and longer-term studies are needed.

Acute post-operative diabetic ketoacidosis: Atypical harbinger unmasking latent diabetes mellitus

Hyperglycaemia following surgical and anaesthetic stress is a well-established entity which might have undesirable clinical consequences in known diabetics. We encountered a rare event where an undiagnosed diabetic patient developed ketoacidosis in the immediate post-operative period which was her initial presenting symptom of deranged glucoregulation. Presumably, the stress induced by surgery and anaesthesia lead to the genesis of this event. We discuss the management of this case. In addition, we highlight the importance of glycosylated haemoglobin as a subject of future research in identifying such “at risk” patients and for stratifying the risk of hyperglycaemic complications in perioperative settings.