Long-term Relapse of Type 2 Diabetes After Roux-en-Y Gastric Bypass: Prediction and Clinical Relevance

Current challenges and future perspectives in treating patients with NAFLD-related cirrhosis

Despite the slow, progressive nature of NAFLD, the number of patients with NAFLD-related cirrhosis has significantly increased. Although the management of patients with cirrhosis is constantly evolving, improving the prognosis of patients with NAFLD-related cirrhosis is a challenge because it is situated at the crossroads between the liver, the metabolic, and the cardiovascular diseases. Therefore, the therapeutic interventions should not only target the liver but also the associated cardiometabolic conditions and should be adapted accordingly. The objective of the current review is to critically discuss the particularities in the management of patients with NAFLD-related cirrhosis. We relied on the recommendations of scientific societies and discussed them in the specific context of NAFLD cirrhosis and the surrounding cardiometabolic milieu. Herein, we covered the following aspects: (1) the weight loss strategies through lifestyle interventions to avoid sarcopenia and improve portal hypertension; (2) the optimal control of metabolic comorbidities in particular type 2 diabetes aimed not only to improve cardiovascular morbidity/mortality but also to lower the incidence of cirrhosis-related complications (we discussed various aspects related to the safety of oral antidiabetic drugs in cirrhosis); (3) the challenges in performing bariatric surgery in patients with cirrhosis related to the portal hypertension and the risk of cirrhosis decompensation; (4) the particularities in the diagnosis and management of the portal hypertension and the difficulties in managing patients awaiting for liver transplantation; and (5) the difficulties in developing drugs and conducting clinical trials in patients with NAFLD-related cirrhosis. Moreover, we discussed the emerging options to overcome these obstacles.

Diagnostic Value of Advanced-DiaRem for Predicting Diabetic remission after One Anastomosis Gastric Bypass/Minigastric Bypass

BACKGROUND

Obesity is a main risk factor for type 2 diabetes. Bariatric surgery can help diabetic patients with obesity. Among different types of metabolic surgeries, one anastomosis gastric bypass (OAGB) surgery is a new procedure.

AIM

To comprehensively determine the diagnostic values of advanced-diabetic remission (Ad-DiaRem), one of the scoring systems, in predicting diabetic remission after OAGB surgery.

METHODS

In this retrospective cohort study, patients aged 18-60 years with type 2 diabetes and obesity, who had undergone OAGB surgery, were included. Diagnostic values of Ad-DiaRem on diabetes remission, after OAGB surgery, which consist of sensitivity (Sen), specificity (Spe), positive and negative predictive values (P/NPV), positive and negative likelihood ratios (P/NLR), accuracy, and odd ratio (OR), were determined.

RESULTS

The percentages of complete diabetic remission after surgery were 56.3% and 53.8% in 12th and 24th months, respectively. The remission cut-off point for Ad-DiaRem was defined 10 considering the highest Youden's index. Among the evaluation indices, the values of Spe, PPV, accuracy, and OR were assigned a high value in both 12th and 24th months of follow-up; however, the area under curve (AUC) was 20% in both.

CONCLUSION

According to our findings, the model of diagnostic values of Ad-DiaRem for predicting diabetic remission should be specified according to race, place of residence, and prevalence of diabetes in society. Presently, this model can be used cautiously until a new model is proposed by further studies.

Prioritising patients for publicly funded bariatric surgery in Queensland, Australia

OBJECTIVES

This study reports the development and pilot application of the Bariatric Surgery Assessment and Prioritisation Tool (BAPT) for use in a public health system. The BAPT was designed as a patient prioritisation instrument to assess patients with excessive weight and type 2 diabetes suitable for bariatric surgery. We assessed whether the instrument successfully identified those who gained the greatest benefits including weight loss, diabetes remission, reduction in comorbidities, and health-related quality of life (HR-QoL).

METHODS

The BAPT instrument was applied to score 292 patients referred for bariatric surgery in Queensland between 2017 and 2020 based on their, body mass index, diabetes status, surgical risk (e.g. pulmonary embolism) and comorbidities (e.g. non-alcoholic steatohepatitis). These data were collected at referral and at 12-months post-surgery for 130 patients and stratified by BAPT scores. Outcomes included clinical and HR-QoL.

RESULTS

Patients' BAPT scores ranged from 12 to 78 (possible range 2-98). Those with higher scores tended to be younger (p < 0.001), have higher BMI (p < 0.001) or require insulin to manage diabetes (p < 0.01). All patients lost similar percentages of body weight (20-25%, p = 0.73) but higher-scoring patients were more likely to discontinue oral diabetes medications (p < 0.001) and the improvement in glycated haemoglobin was four times greater in patients scoring 70-79 points compared to those scoring 20-29 (p < 0.05). Those who scored ≥ 50 on the BAPT were substantially more likely to obtain diabetes remission (57% vs 31%). BAPT scores of 40 and above tended to have greater improvement in HR-QoL.

CONCLUSIONS

The BAPT prioritised younger patients with higher BMIs who realised greater improvements in their diabetes after bariatric surgery. Higher-scoring BAPT patients should be prioritised for bariatric surgery as they have a greater likelihood of attaining diabetes remission.

Bariatric surgery and diabetes: Current challenges and perspectives

Diabetes mellitus (DM) and obesity have become public issues of global concern. Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach; however, there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM. In this review, we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM. I believe that our insights will be of great help to clinicians in their daily practice.

Weight loss benefits on HDL cholesterol persist even after weight regaining

BACKGROUND

Obesity-related comorbidities may relapse in patients with weight regain after bariatric surgery. However, HDL cholesterol (HDLc) levels increase after surgery and seem to remain stable despite a gradual increase in BMI. The aim of this study is to analyze the effects of weight regain after bariatric surgery on HDL cholesterol.

MATERIALS AND METHODS

This is a retrospective, observational, cohort study in patients who underwent bariatric surgery in the Hospital de la Santa Creu i Sant Pau (Barcelona) between 2007 and 2015. Patients without at least 5 years of follow-up after surgery, under fibrate treatment, and those who required revisional surgery were excluded from the analysis. Data were collected at baseline, 3 and 6 months after surgery, and then annually until 5 years post-surgery.

RESULTS

One hundred fifty patients were analyzed. 93.3% of patients reached > 20% of total weight loss after surgery. At 5th year, 37% of patients had regained > 15% of nadir weight, 60% had regained > 10%, and 22% had regained < 5% of nadir weight. No differences were found in HDLc levels between the different groups of weight regain, nor in the % of change in HDLc levels between nadir weight and 5 years, or in the proportion of patients with normal HDLc concentrations either.

CONCLUSION

HDLc remains stable regardless of weight regain after bariatric surgery.

Preoperative predictors of type 2 diabetes remission after bilio-pancreatic diversion with duodenal switch

BACKGROUND

Many patients achieve short-term type 2 diabetes (T2D) remission after bariatric surgery, but relapses are common. Diabetes outcomes after bariatric surgery vary across procedures and populations. T2D remission scores are simple clinical tools developed to predict remission after bariatric surgery. However, they have never been tested after Biliopancreatic diversion with duodenal switch (BPD-DS).

OBJECTIVES

The aim of this study was to compare the predictive value of T2D remission scores and preoperative diabetes characteristics in predicting T2D remission after BPD-DS.

SETTING

Quebec Heart and Lung Institute - Laval University.

METHODS

We retrospectively identified 918 patients with preoperative T2D who had undergone BPD-DS. Retrospective chart review was performed and variables used to calculate predictive scores were captured. T2D status was assessed annually for up to 10 years postop. Predictive values for each score (DiarRem, Ad Diarem, and Diabetter) and single preoperative diabetes characteristics used to construct these algorithms were evaluated by area under receiver operating characteristic curves (AUC).

RESULTS

Diabetter showed greater performance for prediction of durable diabetes remission than other algorithms with acceptable discriminative ability (AUC between .69 and .79), but was not superior to T2D duration as a single predictor (P = .24 and P = .18). At 10 years, T2D duration had a better discriminative ability for the prediction of T2D remission than all 3 predictive models (AUC = .85, P < .05).

CONCLUSIONS

Better chances for T2D remission following BPD-DS are associated with a shorter duration or T2D before surgery. Duration of T2D alone offers an excellent predictive ability and is a convenient alternative to diabetes remission scores to estimate chances of long-term diabetes remission after BPD-DS.

Comparison of scoring systems for predicting short- and long-term type 2 diabetes remission after bariatric surgery

INTRODUCTION

Our study aimed to compare the short- and particularly long-term type 2 diabetes mellitus (T2DM) remission prediction abilities of ABCD, individualised metabolic surgery (IMS), DiaRem2, Ad-DiaRem and DiaBetter scoring systems in Turkish adult type 2 diabetic morbidly obese patients who underwent bariatric surgery.

PATIENTS AND METHODS

Our study was planned as a retrospective cohort study. A total of 137 patients with T2DM, including 78 sleeve gastrectomy (SG) and 59 Roux-en-Y gastric bypass (RYGB) patients, were included in the 1st-year evaluation after bariatric surgery, and a total of 115 patients with T2DM, including 64 SG and 51 RYGB patients, were included in the evaluation at the end of the 5th year.

RESULTS

In the 1st year after bariatric surgery, area under the ROC curve (AUC) values for diabetes remission scores were 0.863 for Ad-DiaRem, 0.896 for DiaBetter, 0.840 for DiaRem2, 0.727 for ABCD and 0.836 for IMS. At 5 years after bariatric surgery, the AUC values for diabetes remission were 0.834 for Ad-DiaRem, 0.888 for DiaBetter, 0.794 for DiaRem2, 0.730 for ABCD and 0.878 for IMS.

CONCLUSIONS

According to our study, the DiaBetter score provided a better AUC value than the other scores both in the short and long term but showed similar predictive performance to Ad-DiaRem in the short term and IMS in the long term. We believe that DiaBetter and Ad-DiaRem scores might be more appropriate for short-term assessment and DiaBetter and IMS scores for long-term remission assessment.

Osteoarthritis in patients with obesity: The bariatric surgery impacts on its evolution

Obesity is one of the main modifiable risk factors for osteoarthritis (OA). Moreover, obesity is associated with greater pain intensity and functional limitation, but also with a significantly lower responder rate to intra-articular treatments. Consequently, an arthroplasty is indicated earlier and more frequently in patients with obesity. However, pain and functional symptoms improve slightly less after arthroplasty in patients with obesity, who display higher incidence of early and late complications following prosthetic surgery. Bariatric surgery (BS) has increased worldwide and is efficient to induce major and sustainable weight-loss. Importantly, BS significantly reduces pain and functional limitation in patients with symptomatic knee OA. Biomarkers analysis also revealed a decrease in catabolic factors and an increase in anabolic one after BS suggesting a structural protective effect in knee OA. Nevertheless, the impact of BS prior to arthroplasty remains unclear. BS seems to decrease short- and mid-term complications such as infections or thrombosis. However, BS does not appear to modify long-term complications rate, and may even increase it, especially revisions and infections. Although few studies have compared the symptomatic and functional outcomes of joint replacement with or without BS, these are not significantly improved by prior BS. Despite these heterogeneous results, medico-economic studies found that BS prior to arthroplasty was cost-effective. To conclude, BS could significantly reduce the symptoms of OA and potentially slow its progression, but appears more disappointing in preventing long-term complications of arthroplasties and improving their functional results.

Barriers to metabolic surgery and how to address them

After bariatric surgery, patients with obesity achieve sustainable weight loss, gain in mobility, quality of life and life expectancy. Bariatric surgery can lead to remission of type 2 diabetes or to long term glycaemic control for patients with type 2 diabetes, while medical treatment has a preventive efficacy on micro and macrovascular complications. This has led to the concept of metabolic surgery to treat type 2 diabetes. Despite the benefits, only a small proportion of eligible patients undergo bariatric/metabolic surgery. Powerful antidiabetic medications, self-estimated lack of knowledge by medical professionals and fear of surgical complications are some of the arguments to prefer medical treatment of type 2 diabetes obesity versus metabolic surgery. We have reviewed in this paper the barriers which explain the low referral rate to metabolic surgery. With the point of view of the diabetologist, the general practitioner and the patient, we have addressed them to help clinicians and patients model an evidenced-based patient-oriented medical plan.

Poly-Agonist Pharmacotherapies for Metabolic Diseases: Hopes and New Challenges

The use of glucagon-like peptide-1 (GLP-1) receptor-based multi-agonists in the treatment of type 2 diabetes and obesity holds great promise for improving glycaemic control and weight management. Unimolecular dual and triple agonists targeting multiple gut hormone-related pathways are currently in clinical trials, with recent evidence supporting their efficacy. However, significant knowledge gaps remain regarding the biological mechanisms and potential adverse effects associated with these multi-target agents. The mechanisms underlying the therapeutic efficacy of GLP-1 receptor-based multi-agonists remain somewhat mysterious, and hidden threats may be associated with the use of gut hormone-based polyagonists. In this review, we provide a critical analysis of the benefits and risks associated with the use of these new drugs in the management of obesity and diabetes, while also exploring new potential applications of GLP-1-based pharmacology beyond the field of metabolic disease.

Strategies to Maintain the Remission of Diabetes Following Metabolic Surgery

Obesity is a major risk factor for type 2 diabetes mellitus (T2DM). Bariatric surgery is the most effective means of inducing weight loss, and can ameliorate or induce the remission of obesity-related metabolic comorbidities, including T2DM. The guidelines for the management of T2DM emphasize weight management and recommend metabolic surgery for the treatment of T2DM accompanied by obesity. However, despite the clear beneficial effects of metabolic surgery, only 20-50% of patients who experience remission will stay in remission over the long term. Moreover, the beneficial effects of metabolic surgery tend to diminish with time, and a subset of patients experience a relapse of their diabetes. Therefore, in the present review, we discuss potential strategies for the maintenance of diabetic remission following metabolic surgery.

Towards precision medicine in bariatric surgery prescription

Obesity is a complex, multifactorial and chronic disease. Bariatric surgery is a safe and effective treatment intervention for obesity and obesity-related diseases. However, weight loss after surgery can be highly heterogeneous and is not entirely predictable, particularly in the long-term after intervention. In this review, we present and discuss the available data on patient-related and procedure-related factors that were previously appointed as putative predictors of bariatric surgery outcomes. In addition, we present a critical appraisal of the available evidence on which factors could be taken into account when recommending and deciding which bariatric procedure to perform. Several patient-related features were identified as having a potential impact on weight loss after bariatric surgery, including age, gender, anthropometrics, obesity co-morbidities, eating behavior, genetic background, circulating biomarkers (microRNAs, metabolites and hormones), psychological and socioeconomic factors. However, none of these factors are sufficiently robust to be used as predictive factors. Overall, there is no doubt that before we long for precision medicine, there is the unmet need for a better understanding of the socio-biological drivers of weight gain, weight loss failure and weight-regain after bariatric interventions. Machine learning models targeting preoperative factors and effectiveness measurements of specific bariatric surgery interventions, would enable a more precise identification of the causal links between determinants of weight gain and weight loss. Artificial intelligence algorithms to be used in clinical practice to predict the response to bariatric surgery interventions could then be created, which would ultimately allow to move forward into precision medicine in bariatric surgery prescription.

Percentage of maximum weight lost as an optimal parameter of weight regain after bariatric surgery in Chinese patients with diabetes

OBJECTIVE

The goal of this study was to compare measures of weight regain (WR) and their association with the glucose metabolism deterioration within 3 years following bariatric surgery among Chinese patients with obesity and type 2 diabetes mellitus (T2DM).

METHODS

Among a retrospective cohort of 249 patients with obesity and T2DM who underwent bariatric surgery and were followed up to 3 years, WR was assessed by weight changes, BMI changes, percentage of presurgery weight, percentage of nadir weight, and percentage of maximum weight lost (%MWL). Glucose metabolism deterioration was defined as a change from an absence of antidiabetic medication use to use, or absence of insulin use to use, or an increase in glycated hemoglobin by at least 0.5% to 5.7% or greater.

RESULTS

A comparison of C-index of glucose metabolism deterioration indicated %MWL had better discriminatory ability versus weight change, BMI change, percentage of presurgery weight, or percentage of nadir weight (all p < 0.01). The %MWL also had the highest prediction accuracy. The optimal %MWL cutoff point was 20%.

CONCLUSIONS

Among Chinese patients with obesity and T2DM who underwent bariatric surgery, WR quantified as %MWL predicted 3-year postoperative glucose metabolism deterioration better than the alternatives; 20% MWL was the optimal cutoff point.

Accuracy of prediction models for long-term type 2 diabetes remission after gastric bypass

AIM

To evaluate the accuracy of DiaBetter, DiaRem, Ad-DiaRem and 5y-Ad-DiaRem scores' at predicting T2D remission 10 or more years after surgery.

METHODS

Patients with obesity and T2D (n = 126) submitted to RYGB with 10 or more years of follow-up. It was a unicentric trial. Pre-operative anthropometric and clinical data was retrieved to calculate DiaRem, DiaBetter, Ad-DiaRem and 5y-Ad-DiaRem scores, while a hospital visit was conducted to assess current diabetes status. The area under the receiver operating characteristic (AUROC) curve was calculated as estimate of the scores' accuracy to predict long-term T2D remission.

RESULTS

Among the entire cohort (n = 126), 70 subjects (55.6%) achieved and maintained T2D remission 10 or more years after RYGB. The 5y-Ad-DiaRem score was the one that depicted the highest discriminative power (AUROC = 0.838) to predict long-term T2D remission when compared to DiaBetter (AUROC = 0.735), DiaRem (AUROC = 0.721) and Ad-DiaRem (AUROC = 0.720).

CONCLUSION

The score with highest accuracy to predict long-term T2D remission after RYGB surgery was the 5y-Ad-DiaRem. Yet, the available scores accuracy to predict T2D remission in the long term is still suboptimal, highlighting the unmet need for a better scoring system.

Factors influencing bariatric surgery outcomes

The outcomes of bariatric surgery, while often impressive, are not universally satisfactory; they vary from patient to patient and from operation to operation. Between 20-30% of patients experience suboptimal weight loss or substantial weight regain early in their postoperative course. Confronted with this chronic disease, and given that failures are difficult to manage, it is essential to better characterize obesity preoperatively, considering other metrics beyond just the body mass index (BMI), to select the best candidates for surgery and optimize the benefit/risk ratio. Based on the data of the most recent studies on bariatric surgery, our objective is to identify the predictive factors of weight loss as well as the risk factors of failure. Our analysis indicates that the choice of the surgical technique, age, initial BMI, ethnic origin, the presence of eating disorders and metabolic factors all have an impact on weight-loss outcomes after bariatric surgery. Thus, it is of major importance to carefully select patients during a preoperative multidisciplinary discussion in order to optimize weight loss and metabolic outcomes.

Efficacy, feasibility and tolerability of ketogenic diet for the treatment of poor response to bariatric surgery

PURPOSE

Poor response to bariatric surgery, namely insufficient weight loss (IWL) or weight regain (WR), is a critical issue in the treatment of obesity. The purpose of our study was to assess the efficacy, feasibility, and tolerability of very low-calorie ketogenic diet (VLCKD) for the management of this condition.

METHODS

A real-life prospective study was conducted on twenty-two patients who experienced poor response after bariatric surgery and followed a structured VLCKD. Anthropometric parameters, body composition, muscular strength, biochemical analyses, and nutritional behavior questionnaires were evaluated.

RESULTS

A significant weight loss (mean 14.1 ± 4.8%), mostly due to fat mass, was observed during VLCKD with the preservation of muscular strength. The weight loss obtained allowed patients with IWL to reach a body weight significantly lower than that obtained at the post-bariatric surgery nadir and to report the body weight of patients with WR at the nadir observed after surgery. The significantly beneficial changes in nutritional behaviors and metabolic profiles were observed without variations in kidney and liver function, vitamins, and iron status. The nutritional regimen was well tolerated, and no significant side effects were detected.

CONCLUSION

Our data demonstrate the efficacy, feasibility, and tolerability of VLCKD in patients with poor response after bariatric surgery.

Bariatric Surgery: Targeting pancreatic β cells to treat type II diabetes

Pancreatic β-cell function impairment and insulin resistance are central to the development of obesity-related type 2 diabetes mellitus (T2DM). Bariatric surgery (BS) is a practical treatment approach to treat morbid obesity and achieve lasting T2DM remission. Traditionally, sustained postoperative glycemic control was considered a direct result of decreased nutrient intake and weight loss. However, mounting evidence in recent years implicated a weight-independent mechanism that involves pancreatic islet reconstruction and improved β-cell function. In this article, we summarize the role of β-cell in the pathogenesis of T2DM, review recent research progress focusing on the impact of Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) on pancreatic β-cell pathophysiology, and finally discuss therapeutics that have the potential to assist in the treatment effect of surgery and prevent T2D relapse.

SICOB-endorsed national Delphi consensus on obesity treatment optimization: focus on diagnosis, pre-operative management, and weight regain/insufficient weight loss approach

PURPOSE

Overweight and obesity affects 60% of adults causing more than 1.2 million deaths across world every year. Fight against involved different specialist figures and multiple are the approved weapons. Aim of the present survey endorsed by the Italian Society of Bariatric Surgery (SICOB) is to reach a national consensus on obesity treatment optimization through a Delphi process.

METHODS

Eleven key opinion leaders (KOLs) identified 22 statements with a major need of clarification and debate. The explored pathways were: (1) Management of patient candidate to bariatric/metabolic surgery (BMS); (2) Management of patient not eligible for BMS; (3) Management of patient with short-term (2 years) weight regain (WR) or insufficient weight loss (IWL); (4) Management of the patient with medium-term (5 years) WR; and (5) Association between drugs and BMS as WR prevention. The questionnaire was distributed to 65 national experts via an online platform with anonymized results.

RESULTS

54 out of 65 invited panelists (83%) respond. Positive consensus was reached for 18/22 statements (82%); while, negative consensus (s20.4; s21.5) and no consensus (s11.5, s17) were reached for 2 statements, respectively (9%).

CONCLUSION

The Delphi results underline the importance of first-line interdisciplinary management, with large pre-treatment examination, and establish a common opinion on how to properly manage post-operative IWL/WR.

LEVEL OF EVIDENCE V

Report of expert committees.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass to Enhance Weight Loss: Single Enterprise Mid-Term Outcomes and Literature Review

Background

Suboptimal weight loss (SWL) occurs up to 30% after sleeve gastrectomy (SG). Conversion to Roux-en-Y gastric bypass (cRYGB) has shown heterogeneous results in terms of additional weight loss and resolution of weight-related comorbidities. We aim to evaluate mid-term outcomes of cRYGB specifically for SWL after SG.

Methods

All patients who underwent cRYGB for SWL from April 2010 to June 2019 from prospective registries at three affiliated tertiary care centers were retrospectively reviewed. Patients who underwent revision or conversion for complications were excluded. Mixed-effects and polynomial regression models were used to evaluate weight loss results after conversion.

Results

Thirty-two patients underwent cRYGB from SG. About 68.7% were women with mean age of 46.6 years. Mean body mass index (BMI) before SG was 55.3 kg/m². Before conversion, mean BMI was 44.5 kg/m² with 17.3% total weight loss (TWL). All procedures were completed laparoscopically in a median surgical time of 183 min. Three major complications occurred (9.3%), one gastrojejunal (GJ) leak and two reoperations. Four cases (12.5%) of GJ stenosis were diagnosed. No mortality was registered. Mean follow-up time was 24 months and patients had 36 kg/m² mean BMI, 17.4% TWL, 27.2% had BMI >35 kg/m².

Conclusions

cRYGB after SG for SWL showed good mid-term results, better than those reported in literature.

Validation of the Individual Metabolic Surgery Score for Bariatric Procedure Selection in the Merged Data of Two Randomized Clinical Trials (SLEEVEPASS and SM-BOSS)

BACKGROUND

LSG and LRYGB are globally the most common bariatric procedures. IMS score categorizes T2D severity (mild, moderate, and severe) based on 4 independent preoperative predictors of long-term remission as follows: T2D duration, number of diabetes medications, insulin use, and glycemic control. IMS score has not been validated in a randomized patient cohort.

OBJECTIVES

To assess the feasibility of individualized metabolic surgery (IMS) score in facilitating procedure selection between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) for patients with severe obesity and type 2 diabetes (T2D).

SETTING

Merged individual patient-level 5-year data of 2 large randomized clinical trials (SLEEVEPASS and SM-BOSS [Swiss Multicenter Bypass or Sleeve Study]).

METHODS

IMS score was calculated for study patients and its performance was analyzed.

RESULTS

One hundred thirty-nine out of 155 patients with T2D had available preoperative data to calculate IMS score as follows: mild stage (n = 41/139), moderate stage (n = 77/139), severe stage (n = 21/139). At 5 years, 135 (87.1%, 67 LSG/68 LRYGB) were available for follow-up and 121 patients had both pre- and postoperative data. Diabetes remission rates according to preoperative IMS score were as follows: mild stage 87.5% (n = 14/16) after LSG and 85.7% (n = 18/21) after LRYGB (P = .999), moderate stage 42.9% (n = 15/35) and 45.2% (n = 14/31) (P = .999), and severe stage 18.2% (n = 2/11) and 0% (n = 0/7) (P = .497), respectively. The T2D remission rate varied significantly between the stages as follows: mild versus moderate odds ratio (OR) 8.3 (95% CI, 2.8-24.0; P < .001), mild versus severe OR 52.2 (95% CI 9.0-302.3; P < .001), and moderate versus severe OR 6.3 (95% CI, 1.3-29.8; P = .020).

CONCLUSIONS

In our study, remission rates of T2D were not statistically different after LSG and LRYGB among all patients and among patients with mild, moderate, and severe diabetes stratified by the IMS score. However, the study may be underpowered to detect differences due to small number of patients in each subgroup. IMS score seemed to be useful in predicting long-term T2D remission after bariatric surgery.

Biochemical Markers and Obstructive Sleep Apnea Risk in Individuals After Long-Term Bariatric Surgery

BACKGROUND

Individuals who have undergone long-term bariatric surgery may be at increased obstructive sleep apnea (OSA) risk. The purpose of this study was to estimate the frequency of OSA risk and its associations, via biochemical markers, in patients who have undergone long-term bariatric surgery.

METHODS

This cross-sectional study evaluated patients after 5 years or more post Roux-en-Y gastric bypass. Biochemical markers, anthropometrics, and OSA risk, via the STOP-Bang score screening tool, were evaluated. Independent Student t, Pearson's chi-squared, or correlation tests were applied, according to total OSA risk score groups or its isolated components.

RESULTS

Among the 77 patients evaluated (88.3% female; body mass index = 32.7 ± 5.8 kg/ m²; postoperative time = 9.9 ± 3.1 years), 36 were at risk for OSA. OSA risk score was positively correlated to high-sensitivity C-reactive protein levels (r² = 0.270; p = 0.025), triglycerides (r² = 0.338, p = 0.004), total cholesterol (r² = 0,262; p = 0,028), and HbA1c (r² = 0.332; p = 0.005). Compared to each counterpart, basal insulin and triglycerides were higher among those who self-reported witnessed apnea (12.8 ± 6.5 vs 8.1 ± 3.8, p = 0.013; 136.4 ± 41.1 vs 88.5 ± 34.8, p = 0.001, respectively), while levels of total cholesterol and LDL-C were higher in participants who reported tiredness (183.9 ± 27.0 vs 164.8 ± 33.4, p = 0.005; 105.9 ± 24.4 vs 92.0 ± 26.6, p = 0.018). Participants with snoring also had higher levels of triglycerides (107 ± 41.1 vs 83.7 ± 33.9, p = 0.010).

CONCLUSIONS

OSA risk was highly prevalent among patients who had undergone long-term bariatric surgery, as noted via increased STOP-Bang scores, as were isolated components related to inflammatory markers and lipid and glycemic profile.

Persistence of severe liver fibrosis despite substantial weight loss with bariatric surgery

BACKGROUND AND AIMS

It remains unclear to what extent and which components of advanced liver disease improve after bariatric surgery. We herein describe the histological outcome in patients with advanced NASH and its relationship with weight loss and metabolic improvement.

APPROACH AND RESULTS

One hundred ninety-six patients with advanced NASH underwent bariatric surgery, 66 of whom agreed to a follow-up liver biopsy at 6 ± 3 years (36 with advanced fibrosis [AF] and 30 with high activity [HA] grade without AF). Liver biopsies LBs were centrally read and histological response was defined as the disappearance of AF or HA. Bariatric surgery induced major histological improvement: 29% of patients had normal histology at follow-up biopsy; 74% had NASH resolution without fibrosis progression; and 70% had ≥1 stage fibrosis regression. However, AF persisted in 47% of patients despite NASH resolution and some degree of fibrosis reversal, only evidenced by the EPoS seven-tier staging classification. These patients had lower weight loss and reduced hypertension or diabetes remission rates. Older age and sleeve gastrectomy were the only independent predictors for persistent AF after adjustment for duration of follow-up. All HA patients had major histological improvement: 50% normal histology, 80% NASH resolution, and 86% a ≥1 grade steatosis reduction. Patients with normal liver at follow-up had the largest weight loss and metabolic improvement. Independent predictors of normal liver were amount of weight loss, high histological activity, and the absence of AF before surgery.

CONCLUSIONS

Although bariatric surgery successfully reverses active steatohepatitis, AF can persist for many years and is associated with lesser weight loss and metabolic improvement. Weight loss alone may not be sufficient to reverse AF.

Effect of exercise training after bariatric surgery: A 5-year follow-up study of a randomized controlled trial

Background and objectives

We previously showed in a 6-month randomized controlled trial that resistance training and protein supplementation after bariatric surgery (Roux-en-Y gastric bypass, RYGB) improved muscle strength without significant effect on weight loss and body composition changes. We performed a 5-year follow-up study in these subjects with the aim 1) to assess the long-term effect of this exercise training intervention and 2) to analyze associations between habitual physical activity (PA) and weight regain at 5 years.

Methods

Fifty-four out of 76 initial participants (follow-up rate of 71%) completed the 5-year follow-up examination (controls, n = 17; protein supplementation, n = 22; protein supplementation and resistance training, n = 15). We measured body weight and composition (DXA), lower-limb strength (leg-press one-repetition maximum) and habitual PA (Actigraph accelerometers and self-report). Weight regain at 5 years was considered low when <10% of 12-month weight loss.

Results

Mean (SD) time elapse since RYGB was 5.7 (0.9) y. At 5 years, weight loss was 32.8 (10.1) kg, with a mean weight regain of 5.4 (SD 5.9) kg compared with the 12-month assessment. Moderate-to-vigorous PA (MVPA) assessed by accelerometry did not change significantly compared with pre-surgery values (+5.2 [SD 21.7] min/d, P = 0.059), and only 4 (8.2%) patients reported participation in resistance training. Muscle strength decreased over time (overall mean [SD]: -49.9 [53.5] kg, respectively, P<0.001), with no statistically significant difference between exercise training intervention groups. An interquartile increase in MVPA levels was positively associated with lower weight regain (OR [95% CI]: 3.27 [1.41;9.86]).

Conclusions

Early postoperative participation in a resistance training protocol after bariatric surgery was not associated with improved muscle strength after 5 years of follow-up; however, increasing physical activity of at least moderate intensity may promote weight maintenance after surgery. PA may therefore play an important role in the long-term management of patients with obesity after undergoing bariatric procedure.

Clinical insights into management options for recurrent type 2 diabetes and cardiovascular risk after metabolic-bariatric surgery

AIMS

Long-term clinical trials evaluating the effects of metabolic-bariatric surgery (MBS) on type 2 diabetes (T2D) demonstrate that a significant proportion of patients either fail to achieve remission or experience T2D recurrence over time. Furthermore, patients with recurrent T2D might require reinstitution of pharmacotherapy to control comorbidities (hypertension, dyslipidemia). This paper reviews therapeutic options in patients with T2D relapse.

DATA SYNTHESIS

Although presently there is no recommended pharmacological strategy, the available data support GLP-1 analogues (GLP-1a) as the most suitable option to control hyperglycemia post-MBS. Beside their efficacy in lowering glycemia and body weight while preserving lean mass, GLP-1a exert cardiovascular/renal-protection and are also safe and well tolerated in surgical patients. In addition, the s.c. route of administration of these medications circumvents the problem of changes in oral drugs bioavailability following MBS. Of note, the available data refers to liraglutide and needs to be confirmed with weekly GLP-1a agents. Information regarding the impact of MBS on the pharmacokinetics of lipid lowering and anti-hypertensive drugs is scarce and inconclusive. The findings indicate that timing from intervention is particularly important because of adaptive intestinal mechanisms.

CONCLUSIONS

The recurrence of T2D following MBS is a clinically relevant issue. GLP-1a therapy represents the best option to improve glycemic and weight control with good tolerability. Long-term clinical trials will clarify the impact of these drugs on cardiovascular outcomes. A close monitoring of MBS patients is advised to guide drug dosage adjustments and ensure the control of cardiovascular risk factors.

Current Applications of Artificial Intelligence in Bariatric Surgery

The application of artificial intelligence technologies is growing in several fields of healthcare settings. The aim of this article is to review the current applications of artificial intelligence in bariatric surgery. We performed a review of the literature on Scopus, PubMed and Cochrane databases, screening all relevant studies published until September 2021, and finally including 36 articles. The use of machine learning algorithms in bariatric surgery is explored in all steps of the clinical pathway, from presurgical risk-assessment and intraoperative management to complications and outcomes prediction. The models showed remarkable results helping physicians in the decision-making process, thus improving the quality of care, and contributing to precision medicine. Several legal and ethical hurdles should be overcome before these methods can be used in common practice.

Five-Year Changes in Weight and Diabetes Status After Bariatric Surgery for Craniopharyngioma-Related Hypothalamic Obesity: a Case-Control Study

PURPOSE

Craniopharyngiomas are tumors located in the hypothalamic region which leads to obesity in about 50% of cases. Long-term efficacy and safety of bariatric surgery are lacking in this peculiar population. The aim of this study is to determine the 5-year weight loss and resolution of type 2 diabetes (T2D) after bariatric surgery in patients operated on craniopharyngioma who had developed hypothalamic obesity.

MATERIALS AND METHODS

This is a multicenter french retrospective case-control study. Subjects with craniopharyngioma (n = 23) who underwent sleeve gastrectomy (SG) (n = 9) or Roux-en-Y gastric bypass (RYGB) (n = 14) (median age 35 years [25;43] and BMI 44.2 kg/m² [40.7; 51.0]; 8/23 with T2D) were individually matched to 2 subjects with common obesity for age, gender, preoperative body mass index, T2D, and type of surgery.

RESULTS

TWL% after 1 and 5 years was lower in the craniopharyngioma group than in the control group: 23.1 [15.4; 31.1] (23/23) vs 31.4 [23.9; 35.3] at 1 year (p = 0.008) (46/46) and 17.8 [7.1; 21.9] (23/23) vs 26.2 [18.9; 33.9] at 5 years (p = 0.003) (46/46). After RYGB, TWL% was lower in the craniopharyngioma group compared to the control group (p < 0.001) and comparable after SG both at 1 and 5 years. No difference between the two groups was observed in T2D remission rate and in early and late adverse events. No hormonal deficiency-related acute disease was reported.

CONCLUSIONS

Bariatric surgery induced a significant weight loss in the craniopharyngioma group at 1 and 5 years, but less than in common obesity. SG may be more effective than RYGB but this remains to be demonstrated in a larger cohort.

Effect of COVID-19 Lockdowns on Physical Activity, Eating Behavior, Body Weight and Psychological Outcomes in a Post-Bariatric Cohort

PURPOSE

Little is known about the consequences of COVID-19 lockdowns on physical activity (PA), eating behavior, and mental health in post-bariatric surgery (BS) patients. We aimed to analyze the relations between changes in PA during COVID-19 lockdowns and changes in body weight and a comprehensive set of lifestyle and psychological outcomes in patients who have undergone BS.

MATERIAL AND METHODS

In April-May 2020 (lockdown#1), we performed an online survey in a cohort of 937 adults who underwent BS and were followed-up at our university medical center for at least one year. We assessed changes in PA, eating behavior, body weight, fatigue, and depression (PHQ-9). In November-December 2020 (lockdown#2), we recorded body weight in 280 patients who had reported decreased PA during lockdown #1.

RESULTS

During lockdown #1 (N = 420 patients included, 44% response rate), decreased PA was reported by 67% patients. Compared to those who reported increased or unchanged PA, patients with decreased PA were more likely to report a ≥ 5% weight gain (OR (95% CI): 3.15 (1.46-7.65), increased fatigue (2.08 (1.36-3.23)), a worsening of eating behavior (2.29 (1.47-3.58)), and moderate-to-severe depressive symptoms (4.74 (2.14-11.76)). During lockdown #2 (N = 225 patients, 80% response rate), significant weight gain since before lockdown #1 was reported (+ 2.8 (95% CI: 1.7-3.8) kg, p < 0.001), with 36% patients reporting a ≥ 5% weight gain.

CONCLUSIONS

PA may counteract detrimental effects of COVID-19 lockdown on post-BS weight trajectories and mental health outcomes. Follow-up measures are needed in this setting to assess the long-term impact of lockdown.

The human gut microbiota contributes to type-2 diabetes non-resolution 5-years after Roux-en-Y gastric bypass

Roux-en-Y gastric bypass (RYGB) is efficient at inducing drastic albeit variable weight loss and type-2 diabetes (T2D) improvements in patients with severe obesity and T2D. We hypothesized a causal implication of the gut microbiota (GM) in these metabolic benefits, as RYGB is known to deeply impact its composition. In a cohort of 100 patients with baseline T2D who underwent RYGB and were followed for 5-years, we used a hierarchical clustering approach to stratify subjects based on the severity of their T2D (Severe vs Mild) throughout the follow-up. We identified via nanopore-based GM sequencing that the more severe cases of unresolved T2D were associated with a major increase of the class Bacteroidia, including 12 species comprising Phocaeicola dorei, Bacteroides fragilis, and Bacteroides caecimuris. A key observation is that patients who underwent major metabolic improvements do not harbor this enrichment in Bacteroidia, as those who presented mild cases of T2D at all times. In a separate group of 36 patients with similar baseline clinical characteristics and preoperative GM sequencing, we showed that this increase in Bacteroidia was already present at baseline in the most severe cases of T2D. To explore the causal relationship linking this enrichment in Bacteroidia and metabolic alterations, we selected 13 patients across T2D severity clusters at 5-years and performed fecal matter transplants in mice. Our results show that 14 weeks after the transplantations, mice colonized with the GM of Severe donors have impaired glucose tolerance and insulin sensitivity as compared to Mild-recipients, all in the absence of any difference in body weight and composition. GM sequencing of the recipient animals revealed that the hallmark T2D-severity associated bacterial features were transferred and were associated with the animals' metabolic alterations. Therefore, our results further establish the GM as a key contributor to long-term glucose metabolism improvements (or lack thereof) after RYGB.

Nomogram for Predicting 5-Year Diabetes Remission After Roux-en-Y Gastric Bypass Surgery in Chinese Patients with Obesity

PURPOSE

Roux-en-Y gastric bypass (RYGB) is widely used as an effective treatment for type 2 diabetes (T2D) patients with obesity; long-term (> 5 years) diabetes remission (DR) rates have been less frequently reported. To date, there is no validated model to guide procedure selection based on long-term glucose control in patients with T2D. The purpose of this study is to establish a new tool for predicting long-term DR with a nomogram.

MATERIALS AND METHODS

One hundred five individuals with complete preoperative information and undergoing RYGB in a university hospital were enrolled in this retrospective study. DR criteria after bariatric surgery were defined according to the 2009 ADA guideline. Fifteen individuals were lost to 5-year follow-up. Thus, 90 individuals were available and seen at the end of follow-up. The baseline and 5-year data of these 90 individuals were analyzed. Multivariate logistic regression analysis was performed to identify independent predictors for long-term DR, and these predictors were used to create a nomogram.

RESULTS

Preoperative glycated hemoglobin (A1C) and diabetes duration were identified as independent influential factors that could be combined for precise prediction of long-term complete DR. We created a nomogram by using these 2 factors. The area under the curve was 0.78 (95% confidence interval 0.67-0.89). The Hosmer-Lemeshow X² value of nomogram was 3.86 (P = 0.87) and indicated consistency between predicted and observed remission.

CONCLUSION

Our nomogram was a novel and useful tool for accurate prediction of long-term DR after RYGB.

Machine learning to guide clinical decision-making in abdominal surgery-a systematic literature review

PURPOSE

An indication for surgical therapy includes balancing benefits against risk, which remains a key task in all surgical disciplines. Decisions are oftentimes based on clinical experience while guidelines lack evidence-based background. Various medical fields capitalized the application of machine learning (ML), and preliminary research suggests promising implications in surgeons' workflow. Hence, we evaluated ML's contemporary and possible future role in clinical decision-making (CDM) focusing on abdominal surgery.

METHODS

Using the PICO framework, relevant keywords and research questions were identified. Following the PRISMA guidelines, a systemic search strategy in the PubMed database was conducted. Results were filtered by distinct criteria and selected articles were manually full text reviewed.

RESULTS

Literature review revealed 4,396 articles, of which 47 matched the search criteria. The mean number of patients included was 55,843. A total of eight distinct ML techniques were evaluated whereas AUROC was applied by most authors for comparing ML predictions vs. conventional CDM routines. Most authors (N = 30/47, 63.8%) stated ML's superiority in the prediction of benefits and risks of surgery. The identification of highly relevant parameters to be integrated into algorithms allowing a more precise prognosis was emphasized as the main advantage of ML in CDM.

CONCLUSIONS

A potential value of ML for surgical decision-making was demonstrated in several scientific articles. However, the low number of publications with only few collaborative studies between surgeons and computer scientists underpins the early phase of this highly promising field. Interdisciplinary research initiatives combining existing clinical datasets and emerging techniques of data processing may likely improve CDM in abdominal surgery in the future.

Intestinal gluconeogenesis shapes gut microbiota, fecal and urine metabolome in mice with gastric bypass surgery

Intestinal gluconeogenesis (IGN), gastric bypass (GBP) and gut microbiota positively regulate glucose homeostasis and diet-induced dysmetabolism. GBP modulates gut microbiota, whether IGN could shape it has not been investigated. We studied gut microbiota and microbiome in wild type and IGN-deficient mice, undergoing GBP or not, and fed on either a normal chow (NC) or a high-fat/high-sucrose (HFHS) diet. We also studied fecal and urine metabolome in NC-fed mice. IGN and GBP had a different effect on the gut microbiota of mice fed with NC and HFHS diet. IGN inactivation increased abundance of Deltaproteobacteria on NC and of Proteobacteria such as Helicobacter on HFHS diet. GBP increased abundance of Firmicutes and Proteobacteria on NC-fed WT mice and of Firmicutes, Bacteroidetes and Proteobacteria on HFHS-fed WT mice. The combined effect of IGN inactivation and GBP increased abundance of Actinobacteria on NC and the abundance of Enterococcaceae and Enterobacteriaceae on HFHS diet. A reduction was observed in the amounf of short-chain fatty acids in fecal (by GBP) and in both fecal and urine (by IGN inactivation) metabolome. IGN and GBP, separately or combined, shape gut microbiota and microbiome on NC- and HFHS-fed mice, and modify fecal and urine metabolome.

Novel Insight into the Mechanism of Metabolic Surgery Causing the Diversity in Glycemic Status in Type 2 Diabetes

Metabolic surgery results in diverse glycemic status in patients with type 2 diabetes (T2D), including hyperglycemia without remission, significant amelioration of hyperglycemia with partial remission, complete restoration of euglycemia, or with prolonged remission, hyperglycemia recurrence in relapses after remission, or post-bariatric hypoglycemia. Unfortunately, it is not known how metabolic surgery leads to this diverse consequence. Here, we discuss the diversity of glycemic status associated with metabolic surgery and the potential mechanisms of T2D remission. We also highlight the relationship between the change in low-grade inflammation and T2D remission after metabolic surgery. We hypothesize that the level of inflammatory and anti-inflammatory cytokines controls the efficacy of metabolic surgery in patients with T2D. This hypothesis may provide further insight into the mechanism of the beneficial effects of metabolic surgery patients with T2D.

Predictors of diabetes relapse after metabolic surgery in Asia

BACKGROUND

Limited studies have focused on diabetes relapse after metabolic surgery, especially among Asians.

OBJECTIVES

To identify the predictors of diabetes relapse following initial postoperative remission in Asia.

SETTING

Four tertiary hospitals METHODS: We assessed 342 patients (age, 41.0 ± 10.8 yr; body mass index [BMI], 39.6 ± 7.3 kg/m²) with complete diabetes data before and 1 and 3 years after metabolic surgery. A total of 290 (84.8%) and 277 (81.0%) patients had diabetes remission at 1 and 3 years after surgery. Logistic regressions were performed to identify the independent predictors of diabetes relapse. Two published predictive models for diabetes remission were also tested for relapse.

RESULTS

Of the 290 patients with 1-year diabetes remission, 29 (10%) experienced a relapse at 3 years after surgery. The area under the receiver operating characteristic curve of the ABCD score in predicting 1-year remission, 3-year remission, and 3-year relapse were .814, .793, and .795, while those of the DiaRem2 score were .823, .774, and .701, respectively. The baseline age, BMI, and insulin use were independent predictors for relapse. The most powerful predictive model for relapse was composed of preoperative insulin use, 1-year A1C, and a change in BMI between the first and third year (C-statistic: .919).

CONCLUSION

The ABCD score predicted both mid-term postoperative diabetes remission and relapse in Asians. Initial older age, lower BMI, insulin use, higher 1-year A1C, and weight regain were independent predictors of relapse. Personalized strategies should be proposed for those at risk of relapse to optimize diabetes outcomes after surgery.

Evaluation of the Effects of Bariatric Surgery in Terms of Weight Loss and Diabetes Remission in the Indian Population

<b><i>Objectives:</i></b> The growing prevalence of obesity rates worldwide is associated with an upsurge in its comorbidities, particularly type 2 diabetes mellitus (T2DM). Bariatric surgery is a proven treatment modality for producing sustained weight loss and resolution of associated T2DM providing marked improvement in quality of life with rapid recovery. This study aims to investigate the effects of laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and mini-gastric bypass (MGB) on obese patients suffering from T2DM in the Indian population and their long-term association with regard to diabetes remission, resolution of comorbidities, and percentage EWL. <b><i>Methods:</i></b> Retrospective data of obese patients with T2DM (preoperative BMI 45.37 ± 8.1) who underwent bariatric surgery (RYGB, LSG, and MGB) were analyzed in this study over a period of 9 years. The mean follow-up period was 2.2 years. Following surgery, the clinical outcome on BMI, resolution of percentage weight loss, and T2DM were studied. The predictive factors of diabetic remission after surgery were determined. Student’s <i>t</i> test and ANOVA and McNemar’s test were applied. <b><i>Results:</i></b> Out of a total of 274 patients, complete remission of T2DM was achieved in 52.9% (<i>n</i> = 145) with mean fasting blood glucose and glycated hemoglobin values being 6.1 ± 0.769 (<i>p</i> = 0.00) at 1 year after surgery. The independent predictive factors of remission were age, gender, BMI, preoperative comorbidities, and % EWL. Gender had no correlation with the chance of achieving disease remission. <b><i>Conclusion:</i></b> Based on our results, bariatric surgery proves to be a successful treatment option resulting in sustained weight loss in obese patients suffering from T2DM. It is found to be beneficial for the long-term resolution of T2DM and improving comorbidities such as hypertension and dyslipidemia. The outcome of the different surgical methods is found to be similar for all patients irrespective of the independent predictors of complete remission.

Prognostic Models for Predicting Remission of Diabetes Following Bariatric Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Remission of type 2 diabetes following bariatric surgery is well established, but identifying patients who will go into remission is challenging.

PURPOSE

To perform a systematic review of currently available diabetes remission prediction models, compare their performance, and evaluate their applicability in clinical settings.

DATA SOURCES

A comprehensive systematic literature search of MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) was undertaken. The search was restricted to studies published in the last 15 years and in the English language.

STUDY SELECTION

All studies developing or validating a prediction model for diabetes remission in adults after bariatric surgery were included.

DATA EXTRACTION

The search identified 4,165 references, of which 38 were included for data extraction. We identified 16 model development and 22 validation studies.

DATA SYNTHESIS

Of the 16 model development studies, 11 developed scoring systems and 5 proposed logistic regression models. In model development studies, 10 models showed excellent discrimination with area under the receiver operating characteristic curve ≥0.800. Two of these prediction models, ABCD and DiaRem, were widely externally validated in different populations, in a variety of bariatric procedures, and for both short- and long-term diabetes remission. Newer prediction models showed excellent discrimination in test studies, but external validation was limited.

LIMITATIONS

While the key messages were consistent, a large proportion of the studies were conducted in small cohorts of patients with short duration of follow-up.

CONCLUSIONS

Among the prediction models identified, the ABCD and DiaRem models were the most widely validated and showed acceptable to excellent discrimination. More studies validating newer models and focusing on long-term diabetes remission are needed.

Predictors of type 2 diabetes relapse after Roux-en-Y Gastric Bypass: a ten-year follow-up study

AIMS

To assess the impact of bariatric surgery on remission and relapse of type 2 diabetes mellitus (T2DM) at 10 years of follow-up and analyze predictive factors.

MATERIALS AND METHODS

Eighty-eight obese subjects undergoing Roux-en-Y gastric bypass (RYGB) and 25 subjects assigned to medical therapy (MT) were evaluated every year for 10 years. T2DM remission was defined by the American Diabetes Association criteria.

RESULTS

Body mass index (BMI), fasting glucose, and hemoglobin A1c (HbA1c) improved more markedly in RYGB than MT patients throughout the 10-year period. Post-surgery remission rates were 74% and 53% at 1 and 10 years, respectively, while remission did not occur in MT patients. One-year post-surgery, BMI decreased more in subjects with remission than in those without, but no further decrease was observed thereafter. By partial-least-squares analysis, T2DM duration, baseline HbA1c, and ensuing insulin therapy were the strongest predictors of remission. Remission was achieved at one year in 91% of patients with T2DM duration < 4 years, and 79% of them remained in remission at 10 years. On the contrary only 42% of patients with T2DM duration ≥ 4 years achieved remission, which was maintained only in 6% at the end of 10 years. By survival analysis, patients with T2DM duration < 4 years had higher remission rates than those with duration ≥ 4 years (hazards ratio (HR) 3.1 [95%CI 1.8-5.7]). Relapse did not occur before two years post-surgery and was much less frequent in patients with < 4- vs ≥ 4-year duration (HR 11.8 [4.9-29.4]).

CONCLUSIONS

Short T2DM duration and good glycemic control before RYGB surgery were the best requisites for a long-lasting T2DM remission, whereas weight loss had no impact on the long-term relapse of T2DM.

Meta-analysis of Long-Term Relapse Rate of Type 2 Diabetes Following Initial Remission After Roux-en-Y Gastric Bypass

This study aims to determine the long-term relapse rate of type 2 diabetes (T2DM) following initial remission after Roux-en-Y gastric bypass (RYGB) surgery. We searched studies in PubMed, Embase, and the Cochrane Library. A total of 17 eligible studies were included for analysis. Meta-analysis suggested a pooled long-term relapse rate of 0.30 (95% confidence interval [CI], 0.26–0.34) and a remission rate of 0.63 (95% CI, 0.55–0.72) after RYGB and a hazard ratio of 0.73 (95% CI, 0.66–0.81) for comparison of RYGB and sleeve gastrectomy (SG). Subgroup analyses established pooled results. This study suggested RYGB may be a preferred regime for obese patients with T2DM because it is associated with lower long-term relapse and relatively higher initial remission and was also superior to SG due to lower risk of recurrence.

Intestinal alteration of α-gustducin and sweet taste signaling pathway in metabolic diseases is partly rescued after weight loss and diabetes remission

Carbohydrates and sweeteners are detected by the sweet taste receptor in enteroendocrine cells (EECs). This receptor is coupled to the gustducin G-protein, which α-subunit is encoded by GNAT3 gene. In intestine, the activation of sweet taste receptor triggers a signaling pathway leading to GLP-1 secretion, an incretin hormone. In metabolic diseases, GLP-1 concentration and incretin effect are reduced while partly restored after Roux-en-Y gastric bypass (RYGB). We wondered if the decreased GLP-1 secretion in metabolic diseases is caused by an intestinal defect in sweet taste transduction pathway. In our RNA-sequencing of EECs, GNAT3 expression is decreased in patients with obesity and type 2 diabetes compared with normoglycemic obese patients. This prompted us to explore sweet taste signaling pathway in mice with metabolic deteriorations. During obesity onset in mice, Gnat3 expression was downregulated in EECs. After metabolic improvement with enterogastro anastomosis surgery in mice (a surrogate of the RYGB in humans), the expression of Gnat3 increased in the new alimentary tract and glucose-induced GLP-1 secretion was improved. To evaluate if high-fat diet-induced dysbiotic intestinal microbiota could explain the changes in the expression of sweet taste α-subunit G-protein, we performed a fecal microbiota transfer in mice. However, we could not conclude if dysbiotic microbiota impacted or not intestinal Gnat3 expression. Our data highlight that metabolic disorders were associated with altered gene expression of sweet taste signaling in intestine. This could contribute to impaired GLP-1 secretion that is partly rescued after metabolic improvement.NEW & NOTEWORTHY Our data highlighted 1) the sweet taste transduction pathway in EECs plays pivotal role for glucose homeostasis at least at gene expression level; 2) metabolic disorders lead to altered gene expression of sweet taste signaling pathway in intestine contributing to impaired GLP-1 secretion; and 3) after surgical intestinal modifications, increased expression of GNAT3, encoding α-gustducin contributed to metabolic improvement.

A Scoping Review of Artificial Intelligence and Machine Learning in Bariatric and Metabolic Surgery: Current Status and Future Perspectives

Artificial intelligence (AI) is a revolution in data analysis with emerging roles in various specialties and with various applications. The objective of this scoping review was to retrieve current literature on the fields of AI that have been applied to metabolic bariatric surgery (MBS) and to investigate potential applications of AI as a decision-making tool of the bariatric surgeon. Initial search yielded 3260 studies published from January 2000 until March 2021. After screening, 49 unique articles were included in the final analysis. Studies were grouped into categories, and the frequency of appearing algorithms, dataset types, and metrics were documented. The heterogeneity of current studies showed that meticulous validation, strict reporting systems, and reliable benchmarking are mandatory for ensuring the clinical validity of future research.

Metabolic and Psychological Features are Associated with Weight Loss 12 Months After Sleeve Gastrectomy

CONTEXT

Laparoscopic sleeve gastrectomy (LSG) is a recognized effective procedure of bariatric surgery, but a poor response in weight loss may still represent a clinical problem. To date there are no validated predictors useful to better perform patient selection.

OBJECTIVE

To establish the association of baseline anthropometric, metabolic, and psychologic features with the percent total weight loss (%TWL) and percent excess weight loss (%EWL) 12 months after surgery.

DESIGN

Retrospective longitudinal analysis of a set of data about obese patients attending the outpatient service of a single obesity center from June 2016 to June 2019.

PATIENTS

A total of 106 obese patients underwent LSG with presurgery evaluation and follow-up at 12 months after surgery.

MAIN OUTCOME

Weight loss 12 months after LSG.

RESULTS

Patients who achieved a %TWL higher than the observed median (≥34%) were younger, with a lower fasting plasma glucose and glycated hemoglobin, with a lower prevalence of hypertension and with a lower score in the impulsiveness scale, compared with patients with a %TWL < 34%. Similar findings were found when %EWL was considered. Multivariable stepwise regression analysis showed that younger age, lower impulsiveness, higher-than-normal urinary free cortisol, and lower HbA1c were associated with higher %TWL, explaining about 31.5% of the weight loss.

CONCLUSION

Metabolic and psychologic features at baseline were independently associated with weight loss and explained a non-negligible effect on the response to LSG. These data suggest that careful metabolic and psychologic profiling could help in sharper indications and personalized pre- and postsurgical follow-up protocols in candidates for LSG.

Is Bariatric Surgery Effective for Chinese Patients with Type 2 Diabetes Mellitus and Body Mass Index < 35 kg/m2? A Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery has been applied for weight loss and comorbidity control in China since 2000. Recent studies have shown positive results for bariatric surgery in patients with a body mass index (BMI) of less than 35 kg/m². However, the effect of surgery on Chinese patients with type II diabetes mellitus (T2DM) has not yet been systematically investigated.

METHODS

A comprehensive literature search was performed in the Cochrane Library, Embase, PubMed, and Web of Science from January 2014 to March 2020. All studies examined bariatric surgery outcomes on Chinese patients at 12-, 36-, and 60-month follow-up. The research followed the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) recommendations.

RESULTS

Eleven studies containing 611 patients were included in this meta-analysis. Clinical indices at 12-, 36-, and 60-month follow-up were analyzed. Significant decreases were identified in body weight, BMI, waist circumference (WC), blood pressure (BP), fasting plasma glucose (FPG), glycosylated hemoglobin A1c (hemoglobin A1c, or HbA1c), triglyceride (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) postoperatively. An increasing trend in the T2DM remission rate was discovered. The remission group was observed to have significantly lower HbA1c and C-peptide level, a shorter duration of T2DM, and a higher BMI than the nonremission group at 12 months.

CONCLUSIONS

Bariatric surgery successfully provided significant BMI control as well as a reduction and normalization of glucose- and lipid-related metabolism at 12, 36, and 60 months postoperatively in Chinese patients with T2DM with a preoperative BMI of less than 35 kg/m². An increasing trend in the T2DM remission rate suggested promising future applications in this population.

Diabetes remission after malabsorptive bariatric surgery

Obesity and diabetes are two closely related disorders. Lifestyle changes and drug treatment do not achieve successful diabetes remission. A treatment option for these patients is bariatric surgery (BS). The partial and complete remission rates vary, depending on the type of technique used (restrictive or malabsorptive), with malabsorptive surgery being more effective in terms of both weight reduction and diabetes remission (DR). Different scales (DiaRem, Ad-DiaRem or 5y-Ad-DiaRem) predict the probability of DR after BS, particularly after gastric bypass surgery. Some studies report higher DR rates in surgery with a greater malabsorptive component. Our aim was to study the benefits of BS at one year and 5 years in terms of the weight and blood glucose profile in patients with obesity and type 2 diabetes mellitus; assess percentage DR according to ADA criteria; determine the DR predictive capacity of different scores; and examine which variables predict DR at one and five years after biliopancreatic diversion (BPD). Percentage overweight reduction and the decrease in both blood glucose and HbA1c were greater with BPD. Complete diabetes remission was approximately 80% at one and 5 years after BS. In general, the scores that determine the probability of DR show poor discriminative capacity in malabsorptive surgery. Presurgery HbA1c predicts DR at one and 5 years after BPD. The type of surgery performed should be individualized, based on the severity of diabetes and the specific characteristics of each patient.

Comparison of Four Risk Prediction Models for Diabetes Remission after Roux-en-Y Gastric Bypass Surgery in Obese Chinese Patients with Type 2 Diabetes Mellitus

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a major type of bariatric surgery. Various models have been established for facilitating clinical decision-making and predicting outcomes after RYGB; the ABCD, DiaRem, advanced-DiaRem (Ad-DiaRem), and DiaBetter scores are among the most commonly used risk prediction models. However, these models were primarily developed based on retrospective analyses of patients from Western countries at 1 year after RYGB. The present study was to assess the performance of these models and identify the optimal model, for predicting postoperative diabetes remission in diabetic Chinese patients.

METHODS

The present study included a total of 253 RYGB patients; 214 completed a 1-year follow-up and 131 completed a 3-year follow-up. The assessments and comparisons of the predictive performance of the four models were based on both discrimination and calibration measures. Discrimination was assessed according to the area under the receiver operating characteristic curve (AUC), and calibration was evaluated by Hosmer-Lemeshow goodness-of-fit tests and predicted-to-observed ratios.

RESULTS

One hundred thirteen (52.8%) in the 1-year follow-up group and 59 (45.0%) in the 3-year follow-up group achieved complete diabetes remission. Although all models showed similar discriminatory capacity and good calibration, the DiaBetter model exhibited the best predictive performance (1-year follow-up, AUC 0.760, 95% confidence interval [CI] 0.697-0.815, predicted-to-observed ratio 1.04; 3-year follow-up, AUC 0.804, 95% CI 0.726-0.868, predicted-to-observed ratio 0.95).

CONCLUSIONS

The present results indicated that the DiaBetter model is the optimal model for predicting postoperative diabetes remission in diabetic Chinese individuals, due to its excellent predictive accuracy and ready availability for use in clinical practice.

Decision Tree for the Performance of Intraoperative Liver Biopsy During Bariatric Surgery

BACKGROUND AND AIMS

Bariatric surgery provides a useful opportunity to perform intraoperative liver biopsy to screen for non-alcoholic steatohepatitis (NASH). There is currently no consensus on whether intraoperative liver biopsy should be systematically performed. The aim of this study was to develop and validate a decision tree to guide that choice.

APPROACH AND RESULTS

This prospective study included 102 consecutive patients from the severe obesity outcome network (SOON) cohort in whom liver biopsy was systematically performed during bariatric surgery. A classification and regression tree (CART) was created to identify the nodes that best classified patients with and without NASH. External validation was performed. Seventy-one biopsies were of sufficient quality for analysis (median body mass index 43.3 [40.7; 48.0] kg/m²). NASH was diagnosed in 32.4% of cases. None of the patients with no steatosis on ultrasound had NASH. The only CART node that differentiated between a "high-risk" and a "low-risk" of NASH was alanine aminotransferase (ALT). ALT>53IU/L predicted NASH with a positive predictive value (PPV) of 68% and a negative predictive value (NPP) of 89%, a sensitivity of 77%, and a specificity of 84%. In the external cohort (n=258), PPV was 68%, NPV was 62%, sensitivity was 27%, and specificity was 90%.

CONCLUSIONS

The present work supports intraoperative liver biopsy to screen for NASH in patients with ALT>53IU/L; however, patients with no steatosis on ultrasound should not undergo biopsy. The CART failed to identify an algorithm with a good sensitivity to screen for NASH in patients with ultrasonography-proven steatosis and ALT≤53IU/L.

Who will benefit from bariatric surgery for diabetes? A protocol for an observational cohort study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) and obesity are pandemic diseases that lead to a great deal of morbidity and mortality. The most effective treatment for obesity and T2DM is bariatric or metabolic surgery; it can lead to long-term diabetes remission with 4 in 10 of those undergoing surgery having normal blood glucose on no medication 1 year postoperatively. However, surgery carries risks and, additionally, due to resource limitations, there is a restricted number of patients who can access this treatment. Moreover, not all those who undertake surgery respond equally well metabolically. The objective of the current research is to prospectively investigate predictors of T2DM response following metabolic surgery, including those directly involved in its aetiopathogenesis such as fat distribution and genetic variants. This will inform development of a clinically applicable model to help prioritise this therapy to those predicted to have remission.

METHODS AND ANALYSIS

A prospective multicentre observational cohort study of adult patients with T2DM and obesity undergoing Roux-en-Y gastric bypass surgery. Patients will be comprehensively assessed before surgery to determine their clinical, metabolic, psychological, genetic and fat distribution profiles. A multivariate logistic regression model will be used to assess the value of the factors derived from the preoperative assessment in terms of prediction of diabetes remission.

ETHICS AND DISSEMINATION

Formal ethics review was undertaken with a favourable opinion (UK HRA RES reference number 18/LO/0931). The dissemination plan is to present the results at conferences, in peer-reviewed journals as well as to lay media and to patient organisations.

TRIAL REGISTRATION DETAILS

ClinicalTrials.gov, Identifier: NCT03842475.

Weight Regain and Insufficient Weight Loss After Bariatric Surgery: Definitions, Prevalence, Mechanisms, Predictors, Prevention and Management Strategies, and Knowledge Gaps-a Scoping Review

Some patients experience weight regain (WR) or insufficient weight loss (IWL) after bariatric surgery (BS). We undertook a scoping review of WR and IWL after BS. We searched electronic databases for studies addressing the definitions, prevalence, mechanisms, clinical significance, preoperative predictors, and preventive and treatment approaches including behavioral, pharmacological, and surgical management strategies of WR and IWL. Many definitions exist for WR, less so for IWL, resulting in inconsistencies in the reported prevalence of these two conditions. Mechanisms and preoperative predictors contributing to WR are complex and multifactorial. A range of the current knowledge gaps are identified and questions that need to be addressed are outlined. Therefore, there is an urgent need to address these knowledge gaps for a better evidence base that would guide patient counseling, selection, and lead to improved outcomes.

Diabetes remission after malabsorptive bariatric surgery

Obesity and diabetes are two closely related disorders. Lifestyle changes and drug treatment do not achieve successful diabetes remission. A treatment option for these patients is bariatric surgery (BS). The partial and complete remission rates vary, depending on the type of technique used (restrictive or malabsorptive), with malabsorptive surgery being more effective in terms of both weight reduction and diabetes remission (DR). Different scales (DiaRem, Ad-DiaRem or 5y-Ad-DiaRem) predict the probability of DR after BS, particularly after gastric bypass surgery. Some studies report higher DR rates in surgery with a greater malabsorptive component. Our aim was to study the benefits of BS at one year and 5 years in terms of the weight and blood glucose profile in patients with obesity and type 2 diabetes mellitus; assess percentage DR according to ADA criteria; determine the DR predictive capacity of different scores; and examine which variables predict DR at one and five years after biliopancreatic diversion (BPD). Percentage overweight reduction and the decrease in both blood glucose and HbA1c were greater with BPD. Complete diabetes remission was approximately 80% at one and 5 years after BS. In general, the scores that determine the probability of DR show poor discriminative capacity in malabsorptive surgery. Presurgery HbA1c predicts DR at one and 5 years after BPD. The type of surgery performed should be individualized, based on the severity of diabetes and the specific characteristics of each patient.

Real-time imputation of missing predictor values improved the application of prediction models in daily practice

OBJECTIVES

In clinical practice, many prediction models cannot be used when predictor values are missing. We, therefore, propose and evaluate methods for real-time imputation.

STUDY DESIGN AND SETTING

We describe (i) mean imputation (where missing values are replaced by the sample mean), (ii) joint modeling imputation (JMI, where we use a multivariate normal approximation to generate patient-specific imputations), and (iii) conditional modeling imputation (CMI, where a multivariable imputation model is derived for each predictor from a population). We compared these methods in a case study evaluating the root mean squared error (RMSE) and coverage of the 95% confidence intervals (i.e., the proportion of confidence intervals that contain the true predictor value) of imputed predictor values.

RESULTS

-RMSE was lowest when adopting JMI or CMI, although imputation of individual predictors did not always lead to substantial improvements as compared to mean imputation. JMI and CMI appeared particularly useful when the values of multiple predictors of the model were missing. Coverage reached the nominal level (i.e., 95%) for both CMI and JMI.

CONCLUSION

Multiple imputations using either CMI or JMI is recommended when dealing with missing predictor values in real-time settings.