Bariatric surgery and diabetes remission: Who would have thought it?

Comparative Analysis of Orthosteric and Allosteric GLP-1R Agonists' Effects on Insulin Secretion from Healthy, Diabetic, and Recovered INS-1E Pancreatic Beta Cells

Despite the availability of different treatments for type 2 diabetes (T2D), post-diagnosis complications remain prevalent; therefore, more effective treatments are desired. Glucagon-like peptide (GLP)-1-based drugs are currently used for T2D treatment. They act as orthosteric agonists for the GLP-1 receptor (GLP-1R). In this study, we analyzed in vitro how the GLP-1R orthosteric and allosteric agonists augment glucose-stimulated insulin secretion (GSIS) and intracellular cAMP production (GSICP) in INS-1E pancreatic beta cells under healthy, diabetic, and recovered states. The findings from this study suggest that allosteric agonists have a longer duration of action than orthosteric agonists. They also suggest that the GLP-1R agonists do not deplete intracellular insulin, indicating they can be a sustainable and safe treatment option for T2D. Importantly, this study demonstrates that the GLP-1R agonists variably augment GSIS through GSICP in healthy, diabetic, and recovered INS-1E cells. Furthermore, we find that INS-1E cells respond differentially to the GLP-1R agonists depending on both glucose concentration during and before treatment and/or whether the cells have been previously exposed to these drugs. In conclusion, the findings described in this manuscript will be useful in determining in vitro how pancreatic beta cells respond to T2D drug treatments in healthy, diabetic, and recovered states.

Updates in metabolic bariatric endoscopy

Obesity and its associated comorbid conditions have been increasing globally. Endoscopic bariatric and metabolic therapies (EBMTs) were initially designed to replicate bariatric surgery physiology for those who are not or choose not to be surgical candidates. Now, newer procedures target the complicated pathophysiology underlying obesity and its comorbidities. EBMT has been categorized based on its therapeutic target (stomach or small intestine), but innovations have expanded to include extraintestinal organs including the pancreas. Gastric EBMTs, namely space-occupying balloons, gastroplasty with suturing or plication, and aspiration therapy, are primarily used for weight loss. Small bowel EBMTs are designed to cause malabsorption, epithelial endocrine remodeling, and other changes to intestinal physiology to ultimately improve the metabolic comorbidities of obesity rather than induce weight loss alone. These include duodenal mucosal resurfacing, endoluminal bypass sleeves, and incisionless anastomosis systems. Extraluminal or pancreatic EBMT is aimed to restore the production of normal pancreatic proteins that are involved in the progression of type 2 diabetes. This review discusses the current and new technologies of metabolic bariatric endoscopy, their pros and cons, and areas for future research.

Impact of Bariatric Surgery on Outcomes of Patients with Inflammatory Bowel Disease: a Nationwide Inpatient Sample Analysis, 2005-2018

PURPOSE

The global prevalence of inflammatory bowel disease (IBD) has steadily risen over the past few decades. Bariatric surgery stands out as an effective strategy for inducing weight loss. This study investigated the impacts of bariatric surgery on the clinical outcomes in patients with IBD.

MATERIALS AND METHODS

Data of hospitalized patients aged ≥ 18 years with IBD were extracted from the Nationwide Inpatient Sample (NIS) 2005-2018. The patients were categorized according to whether they underwent bariatric surgery or not. Univariate and multivariable logistic regression analyses were performed to determine the associations between bariatric surgery, prolonged LOS, unfavorable discharge, hospital mortality, and morbidity.

RESULTS

Data from 807,843 hospitalized patients with IBD were extracted. After exclusions and propensity-score matching, 80,545 patients were analyzed, with 16,109 undergoing bariatric surgery and 64,436 not. A total of 23% of patients had a prolonged LOS, 8% had unfavorable discharge, and the mortality rate was 1.2%. Multivariable analyses revealed that, compared to patients without bariatric surgery, patients with bariatric surgery had significantly decreased odds of prolonged LOS (adjusted odds ratio [aOR], 0.89; 95% CI 0.85-0.93), unfavorable discharge (aOR, 0.83; 95% CI: 0.77-0.89), and mortality (aOR, 0.54; 95% CI: 0.44-0.67), but had increased odds of morbidity (aOR, 1.09; 95% CI 1.04-1.13).

CONCLUSION

In adults with IBD, bariatric surgery is associated with favorable outcomes concerning hospital LOS, discharge status, and mortality. However, the risk of overall morbidity is slightly increased in those who received bariatric surgery compared to those who did not.

Single-Anastomosis Sleeve Jejunal Bypass as a Treatment for Morbid Obesity: A Systematic Review and Meta-Analysis

Single-anastomosis sleeve jejunal (SASJ) bypass is a bariatric surgery technique with promising results. However, evidence of its efficacy and safety is still lacking. This study aimed to summarize the evidence regarding the efficacy and safety of SASJ bypass surgery in the treatment of morbid obesity. The literature was searched for English-language studies published from inception till November 26, 2023, on MEDLINE/PubMed, Cochrane Library, Web of Science, ProQuest, Scopus, SCINAPSE, and Google Scholar. The search terms included "morbid obesity," "bariatric surgery," and "single anastomosis sleeve jejunal bypass." Extracted data included the body mass index (BMI) before and after surgery, percent total weight loss (%TWL), percent excess weight loss (%EWL), and improvement in preoperative comorbidities. Pooling of the data was done using random effects or fixed-effect models based on the presence of significant heterogeneity. Nine studies were included in this systematic review and meta-analysis. The change in BMI from baseline at 12 months after SASJ bypass was significant (standardized mean difference (SMD) = -3.576, 95% confidence interval (CI) = -5.423, -1.730; I² = 99.23%). At 12 months after surgery, the pooled %TWL was 42.526 (95% CI = 37.948, 47.105; I² = 97.15%), and the pooled %EWL was 75.258 (95% CI = 67.061, 83.456; I² = 99.26%). The pooled incidence of postoperative improvement in diabetes mellitus was 91% (95% CI = 79.6%, 98%, I² = 82%). The overall rate of complications was 9.9% (95% CI = 2.5%, 21.6%; I² = 92.64%). Regarding the short- and mid-term outcomes, SASJ bypass is a safe and effective procedure for weight loss in patients with morbid obesity, with an acceptable rate of complications. The procedure is also associated with a marked improvement in obesity-related comorbidities.

The association between biomarker angiopoietin-like protein five and obstructive sleep apnea in patients undergoing bariatric surgery

PURPOSE

Obstructive sleep apnea (OSA) is prevalent in the bariatric population. OSA should be recognized in patients undergoing bariatric surgery preoperatively to prevent peri- and post-operative complications. Lipid metabolism-related biomarkers are associated with OSA. Triglyceride metabolism is, among others, regulated by angiopoietin-like protein five (ANGPTL5). We aimed to evaluate the level of ANGPTL5 in patients with OSA of different severity levels before and after bariatric surgery.

METHODS

We performed a single-center prospective cohort study including a consecutive series of patients who underwent bariatric surgery. We collected the clinical data, polysomnography (PSG) or polygraphy (PG) parameters, and plasma derived via venipuncture before and 6 to 12 months after surgery. Lipid profile, glucose levels, and ANGPTL5 levels were assessed. ANGPTL5 levels were measured using an enzyme-linked immunosorbent assay (ELISA).

RESULTS

The study included 88 patients for analysis. The patients were divided into two subgroups: no or mild OSA (apnea-hypopnea index (AHI) < 15 events/hour, n = 57) and moderate-to-severe OSA (AHI ≥ 15 events/hour, n = 31). The ANGPTL5 level was higher in the moderate-to-severe OSA group (20.5 [15.6, 26.5] ng/mL) compared to the no or mild OSA group (16.3 [12.5, 19.4] ng/mL) (p = 0.008). A significant positive correlation was observed between ANGPTL5 and AHI (ρ = 0.256, p = 0.017), apnea index (AI) (ρ = 0.318, p = 0.003), and triglyceride levels (ρ = 0.240, p = 0.025). ANGPTL5 levels were reduced significantly after bariatric surgery in both moderate-to-severe OSA (15.6 [10.3, 18.7] ng/mL) and no or mild OSA (13.4 [9.2, 15.8] ng/mL) groups, though to a lower level in the group without or mild OSA. Post-surgery, the significant positive correlation between ANGPTL5 and AHI (ρ = 0.210, p = 0.047), AI (ρ = 0.230, p = 0.034), and triglyceride (ρ = 0.397, p < 0.001) remained.

CONCLUSION

The data showed increased levels of ANGPTL5 in patients with moderate-to-severe OSA. Both AHI and ANGPTL5 levels decreased significantly after bariatric surgery. We also report an association between ANGPTL5 levels and OSA severity.

Effect of Bariatric Surgery on Metabolic Syndrome, Framingham Risk Scores and Thyroid Function during One-Year Follow-Up: A Saudi Retrospective Study

Bariatric surgery (BS) has been demonstrated to achieve sustained weight loss with significant metabolic improvement, including a reduction in cardiovascular disease and diabetes. The aim of this retrospective study is to measure the effect of BS on the Framingham risk score (FRS) and metabolic syndrome (MetS) among patients who underwent bariatric surgery. Additionally, we determine the effect of BS on thyroid-stimulating hormone (TSH) among euthyroid obese patients. A retrospective follow-up study was conducted at King Abdullah Medical City, Makkah, Saudi Arabia. A total of 160 patients underwent BS and completed one-year follow-up visits. Medical history, anthropometric, biochemical, and hormonal parameters were evaluated at baseline and 3−12 months after BS. The International Diabetes Federation (IDF) criteria were used to diagnose MetS. There was a significant decrease in systolic blood pressure (SBP), diastolic blood pressure (DBP), glycated hemoglobin (Hba1c), TSH, low-density lipoprotein (LDL), triglycerides, and total cholesterol (p < 0.001). A significant decrease was seen in MetS, BMI, FRS, SBP, DBP, Hba1c, LDL, triglycerides, cholesterol, and liver enzymes, with a significant increase in high-density lipoprotein levels 12 months postoperatively (p < 0.001). At 12 months, the prevalence of MetS, DM, and HTN and the FRS significantly decreased from 72.5%, 43.1%, 78.1%, and 11.4 to 16.3%, 9.4%, 22.5%, and 5.4, respectively. In addition to achieving substantial weight loss, BS improves MetS prevalence and cardiovascular risk profiles.

Antiobesity Activity of Two Polyherbal Formulations in High-Fat Diet-Induced Obese C57BL/6J Mice

Obesity and overweight have posed a severe threat to humanity, needing urgent efforts for the development of safe and effective therapeutic interventions. In this research work, we have developed two polyherbal formulations A and B basically consisting of Helianthus tuberosus root powder (also called inulin of synanthrin) along with other herbs for the treatment of obesity. Evaluation of the antioxidant activity of both formulations using 1,1-diphenyl-2-picrylhydrazyl (DPPH) and 2,2′-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid) (ABTS) free radical scavenging assays showed good antioxidant potentials. Both formulations A and B showed good antiobesity activity on a diet-induced obesity (DIO) model of mice by effectively lowering the body weight of mice compared to the high-fat diet (HFD) control mice, mainly by reducing the food efficiency ratio (FER). Furthermore, both formulations ameliorated lipoprotein misbalances induced by obesity and thus decreased the atherogenic index. Treatment with both formulations significantly decreased the liver and epididymal white adipose tissue (WAT) weight. This was supported by the improvement in steatosis of the liver and reduced hypertrophy in WAT on histological examination. In addition, formulations A and B have been seen as effective in controlling fasting blood glucose levels probably by alleviating HFD-induced insulin resistance. All of these results collectively suggest that formulations A and B serve as potentially safe and effective herbal interventions to control obesity and its comorbidities.

Messages from the Small Intestine Carried by Extracellular Vesicles in Prediabetes: A Proteomic Portrait

Extracellular vesicles (EVs) mediate communication in physiological and pathological conditions. In the pathogenesis of type 2 diabetes, inter-organ communication plays an important role in its progress and metabolic surgery leads to its remission. Moreover, gut dysbiosis is emerging as a diabetogenic factor. However, it remains unclear how the gut senses metabolic alterations and whether this is transmitted to other tissues via EVs. Using a diet-induced prediabetic mouse model, we observed that protein packaging in gut-derived EVs (GDE), specifically the small intestine, is altered in prediabetes. Proteins related to lipid metabolism and to oxidative stress management were more abundant in prediabetic GDE compared to healthy controls. On the other hand, proteins related to glycolytic activity, as well as those responsible for the degradation of polyubiquitinated composites, were depleted in prediabetic GDE. Together, our findings show that protein packaging in GDE is markedly modified during prediabetes pathogenesis, thus suggesting that prediabetic alterations in the small intestine are translated into modified GDE proteomes, which are dispersed into the circulation where they can interact with and influence the metabolic status of other tissues. This study highlights the importance of the small intestine as a tissue that propagates prediabetic metabolic dysfunction throughout the body and the importance of GDE as the messengers. Data are available via ProteomeXchange with identifier PXD028338.

Five-Year Outcomes of Sleeve Gastrectomy in Patients with Class I Obesity and Type 2 Diabetes Mellitus

BACKGROUND

Several studies have reported short and medium-term outcomes of laparoscopic sleeve gastrectomy (LSG) in patients with class I obesity and type 2 diabetes mellitus (T2DM). However, literature on outcomes beyond three years is scarce. The present study discusses the 5-year results of a previously reported cohort of 20 patients with class I obesity and T2DM, who had undergone LSG between March 2012 and March 2015.

MATERIALS AND METHODS

Patients were followed up in the bariatric clinic at yearly intervals as per institute protocol. Primary outcome was proportion of patients with a glycated haemoglobin (HbA1c) level of 6.5% or less, 5 years after LSG. Secondary outcomes were percentage total weight loss (%TWL), excess weight loss (EWL), weight regain and complications.

RESULTS

Out of 20 patients, 9 (45%) were male and 11 (55%) were female. Mean age was 41.6 ± 9.5 years. Mean pre-operative weight and BMI were 94.8 ± 14.4 kg and 33.4 ± 1.2 kg/m², respectively. Median duration of diabetes was 42 months. Mean pre-operative fasting plasma glucose (FPG) and HbA1c were 171.1 ± 56.8 mg/dL and 8.7 ± 1.6%, respectively. Of the 17 patients available for follow-up at 5 years, 9 (52.9%) achieved HbA1c < 6.5% without medication, while 7 (41.2%) patients had improvement of their glycaemic status. One patient had recurrence of diabetes after initial remission. Mean %TWL and %EWL were 18% and 65.1%, respectively.

CONCLUSION

Laparoscopic sleeve gastrectomy is a reasonable option as a metabolic procedure for patients with T2DM and class I obesity.

A Review of Current Trends with Type 2 Diabetes Epidemiology, Aetiology, Pathogenesis, Treatments and Future Perspectives

Type 2 diabetes (T2D), which has currently become a global pandemic, is a metabolic disease largely characterised by impaired insulin secretion and action. Significant progress has been made in understanding T2D aetiology and pathogenesis, which is discussed in this review. Extrapancreatic pathology is also summarised, which demonstrates the highly multifactorial nature of T2D. Glucagon-like peptide (GLP)-1 is an incretin hormone responsible for augmenting insulin secretion from pancreatic beta-cells during the postprandial period. Given that native GLP-1 has a very short half-life, GLP-1 mimetics with a much longer half-life have been developed, which are currently an effective treatment option for T2D by enhancing insulin secretion in patients. Interestingly, there is continual emerging evidence that these therapies alleviate some of the post-diagnosis complications of T2D. Additionally, these therapies have been shown to induce weight loss in patients, suggesting they could be an alternative to bariatric surgery, a procedure associated with numerous complications. Current GLP-1-based therapies all act as orthosteric agonists for the GLP-1 receptor (GLP-1R). Interestingly, it has emerged that GLP-1R also has allosteric binding sites and agonists have been developed for these sites to test their therapeutic potential. Recent studies have also demonstrated the potential of bi- and tri-agonists, which target multiple hormonal receptors including GLP-1R, to more effectively treat T2D. Improved understanding of T2D aetiology/pathogenesis, coupled with the further elucidation of both GLP-1 activity/targets and GLP-1R mechanisms of activation via different agonists, will likely provide better insight into the therapeutic potential of GLP-1-based therapies to treat T2D.

Systematic review of the outcome of single-anastomosis sleeve ileal (SASI) bypass in treatment of morbid obesity with proportion meta-analysis of improvement in diabetes mellitus

BACKGROUND

Single-anastomosis sleeve ileal (SASI) bypass has emerged as a promising bariatric and metabolic procedure. We aimed to review the current literature on the outcome of SASI procedure in terms of weight loss, improvement in comorbidities, and complications.

METHODS

We conducted a systematic literature search, querying electronic databases and Google Scholar, for studies that reported the outcome of the SASI bypass. The main outcome measures of the review were change in body mass index (BMI), % of excess weight loss (%EWL), improvement in comorbidities, and complications after SASI bypass.

RESULTS

This systematic review comprised ten studies including 941 patients with a median BMI of 45.6 kg/m². The median %EWL at 6 months was 59.4% and significantly (p = 0.04) increased to 90.1% at 12 months. The weighted mean rate of improvement in diabetes mellitus was 99.1 (95%CI: 98.2-99.9, I² = 0). The crude percentages of patients with improvement in hypertension, hyperlipidemia, and gastroesophageal reflux disease were 51%, 76.6%, and 92%, respectively. The median operation time was 111.3, ranging between 75 and 148.4 min. Complications were recorded in 116 (12.3%) patients. Longer common limb was associated with less %EWL at 6 months and less complications whereas larger anastomosis size was associated with higher weight loss and greater improvement in hypertension.

CONCLUSIONS

SASI bypass was associated with good short-term outcomes in regard to weight loss and improvement in comorbidities, namely diabetes mellitus with an acceptably low complication rate.

Evaluating the Pharmacoeconomic Impact of Nutrient Supplementation Post-operatively on Patients Receiving Roux-Y Gastric Bypass vs. Biliopancreatic Diversion with Duodenal Switch

Background

Without the needed medical support, bariatric surgery can be associated with post-operative malnutrition and associated nutrient deficiencies. We aimed to evaluate the cost difference of perioperative infusion requirements and TPN between GBP and BPD-DS.

Methods

All patients undergoing GBP or BPD-DS procedures between August 2015 and June 2018 were included. Information was collected to standardize the nutritional information into two categories: (1) oral supplementation and standard intravenous infusions, as predicted costs forming part of preoperative quote and (2) infusions prescribed for malnutrition, based on blood biochemistry, caterized as unexpected costs.

Results

A total of 573 patients over 3 years (GBP 60%, BPD-DS 40%) were included in the analysis. The average predicted costs from oral supplementation for both surgery groups and prophylactic infusions for BPD-DS were GBP (46.90USD) vs. BPD-DS (154.13 USD) (p-value = NS). Unexpected costs for infusions to correct nutritional deficiencies were GBP (199.14 USD) vs. BPD-DS (127.29 USD) (p-value = NS). TPN incidence rate was GBP (2.1%) and BPD-DS (12.7%) (p-value < 0.001) and admission rate per patient was GBP (0.9) and BPD-DS (0.63) (p-value < 0.05). Costs for acquiring TPN were GBP (153.58 USD) vs. BPD-DS (268.76 USD). Total unexpected costs were GBP (352.72 USD) vs. BPD-DS (396.05 USD) (p-value = NS).

Conclusion

Nutrient deficiencies are known to occur within both GBP and BPD-DS surgeries, even up to 3 years. The admission rate/patient, requiring TPN, was higher in the GBP group, indicating that BPD-DS surgery can be efficient and cost-effective with holistic and multitherapeutic post-surgery care. BPD-DS procedures should be reserved for centers with a comprehensive and experienced multidisciplinary team enforcing stringent follow-up regimes.

Role of Imaging in Bariatric Surgery: A Review of the Various Surgical Techniques and Their Complications

According to the World Health Organization, obesity has reached epidemic proportions globally, with at least 2.8 million people dying each year as a result of being overweight or obese. Bariatric surgery is being increasingly used as a form of treatment, particularly in those patients where lifestyle modifications are deemed insufficient. With the role of radiologists transitioning from a medical to a surgical evaluation in obesity, it is becoming increasingly important to familiarize oneself with the various imaging techniques used in the preoperative and postsurgical evaluation in such cases. This article aims to review the various surgeries performed, their normal imaging appearance, and the various complications that could be encountered.

Impact of Metabolic Surgery on Type-2 Diabetes Remission

Diabetes Mellitus is characterized by numerous metabolic disorders, which have in common the serum elevation of glucose, caused for a pancreatic malfunction in insulin secretion and / or its action. It is a non-communicable disease, considered major public health problems and generalized growth worldwide, being a chronic disease, which can generate a high treatment cost. Metabolic surgery is a safe treatment, regulated by the Federal Council of Medicine and useful in treating people with BMI over 30 years of age, who are unable to control pathologies associated with obesity, primarily type 2 diabetes. The general objective of this study is to understand through a literature review the main impacts of metabolic surgery about the remission of DM 2. This present study it is an exploratory and descriptive study carried out through a literature review. Data were collected through research in virtual health databases, at the Virtual Health Library - VHL, Latin American and Caribbean Health Sciences Information System, LILACS, National Library of Medicine - MEDLINE, Scielo, USP database, PUBMED theses and books. Metabolic surgery proof be a good and effective treatment for having and maintaining good weight loss, as well as a significant clinical and metabolic improvement that extends beyond weight loss. Metabolic surgery is a satisfactory way of achieving long-term weight reduction in obese individuals, increasing survival for these patients. Obese patients with DM2 have a long-term remission of DM2 after bariatric / metabolic surgery. Therefore, it concludes that such procedure is effective in the treatment of the disease and other diseases associated with obesity.

Evaluating the Homeostasis Assessment Model Insulin Resistance and the Cardiac Autonomic System in Bariatric Surgery Patients: A Meta-Analysis

Morbid obesity is a severe chronic disease and subject to surgical methods for losing weight. This intervention is expected to drive to better quality of life and health status. Other important aspects which may be influenced are: HOMA-IR (as insulin resistance marker) and heart rate variability (as cardiac function and autonomic nervous system marker), which are independent and valid predictors of future cardiac, neurological, metabolic health. We pooled 4 studies (646 subjects) resulting to HOMA-IR and nine HRV components-grouped in those undergone to gastric bypass (RYGP) and those operated with vertical sleeve gastrectomy (SG) method. We performed a meta-analysis in patients for HOMA-IR and HRV, using Hedge's g correction of Cohen d for small samples. We concluded that RYGP favors insulin resistance decrease, whereas SG increases the vagal tone, improving cardiac function. The severity of cardiovascular diseases history suggests the selection of the surgery method: SG for the most severe cardiovascular cases and RYGP for those with higher HOMA-IR.

Type 2 Diabetes Mellitus (T2DM) "Remission" in Non-bariatric Patients 65 Years and Older

Objective: To analyze the factors associated with type 2 diabetes mellitus (T2DM) “remission” in non-bariatric Medicare patients 65 years and older.

Research Design and Methods: A retrospective cohort analysis of a Medicare Advantage health plan was conducted using administrative data. An individual was identified as T2DM if the individual had: ≥ 2 medical claims for T2DM coded 250.xx excluding type 1 diabetes; or ≥ 2 pharmacy claims related to T2DM; or ≥ 2 combined medical claims, pharmacy claims for T2DM in 12 months. A T2DM individual was in “remission” if they had no T2DM related claims for more than 12 months continuously. This is different from the standard American Diabetes Association (ADA) definition of remission which includes HbA1c values and hence is represented in quotation (as “remission”). 10,059 T2DM individuals were evaluated over a period of 8 years from 2008 to 2015. Cox proportional hazards was used to identify significant variables associated with T2DM “remission.”

Results: 4.97% of patients studied met the definition of T2DM “remission” in the study cohort. After adjusting for covariates this study found a number of variables associated with T2DM “remission” that were not previously reported: no statin use; low diabetes complications severity index score; no hypertension; no neuropathy; no retinopathy; race (non-white and non-African American); presence of other chronic ischemic heart disease (IHD) and females (p < 0.05).

Conclusion: T2DM “remission” in Medicare patients 65 years and older is observed in a community setting in a small proportion of non-bariatric patients.

Metabolic and Endocrine Consequences of Bariatric Surgery

Obesity is one of the most serious worldwide epidemics of the twenty-first century according to the World Health Organization. Frequently associated with a number of comorbidities, obesity threatens and compromises individual health and quality of life. Bariatric surgery (BS) has been demonstrated to be an effective treatment to achieve not only sustained weight loss but also significant metabolic improvement that goes beyond mere weight loss. The beneficial effects of BS on metabolic traits are so widely recognized that some authors have proposed BS as metabolic surgery that could be prescribed even for moderate obesity. However, most of the BS procedures imply malabsorption and/or gastric acid reduction which lead to nutrient deficiency and, consequently, further complications could be developed in the long term. In fact, BS not only affects metabolic homeostasis but also has pronounced effects on endocrine systems other than those exclusively involved in metabolic function. The somatotropic, corticotropic, and gonadal axes as well as bone health have also been shown to be affected by the various BS procedures. Accordingly, further consequences and complications of BS in the long term in systems other than metabolic system need to be addressed in large cohorts, taking into account each bariatric procedure before making generalized recommendations for BS. In this review, current data regarding these issues are summarized, paying special attention to the somatotropic, corticotropic, gonadal axes, and bone post-operative health.

Network meta-analysis of the relative efficacy of bariatric surgeries for diabetes remission

BACKGROUND

Bariatric surgery leads to a higher remission rate for type 2 diabetes mellitus than non-surgical treatment. However, it remains unsolved which surgical procedure is the most efficacious. This network meta-analysis aimed to rank surgical procedures in terms of diabetes remission.

METHODS AND FINDINGS

We electronically searched for randomized controlled trials in which at least one surgical treatment was included among multiple arms and the diabetes remission rate was included in study outcomes. A random-effects network meta-analysis was performed within a frequentist framework. The hierarchy of treatments was expressed as the surface under the cumulative ranking curve value. Results of the analysis of 25 eligible randomized controlled trials that covered non-surgical treatments and eight surgical procedures (biliopancreatic diversion [BPD], BPD with duodenal switch, Roux-en Y gastric bypass, mini gastric bypass [mini-GBP], laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, greater curvature plication and duodenal-jejunal bypass) showed that BPD and mini-GBP had the highest surface under the cumulative ranking curve values among the eight surgical treatments.

CONCLUSION

Current network meta-analysis indicated that BPD or mini-GBP achieved higher diabetes remission rates than the other procedures. However, the result needs to be interpreted with caution considering that these procedures were in the minority of bariatric surgeries.

Weight-Independent Mechanisms of Glucose Control After Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass results in large and sustained weight loss and resolution of type 2 diabetes in 60% of cases at 1-2 years. In addition to calorie restriction and weight loss, various gastro-intestinal mediated mechanisms, independent of weight loss, also contribute to glucose control. The anatomical re-arrangement of the small intestine after gastric bypass results in accelerated nutrient transit, enhances the release of post-prandial gut hormones incretins and of insulin, alters the metabolism and the entero-hepatic cycle of bile acids, modifies intestinal glucose uptake and metabolism, and alters the composition and function of the microbiome. The amelioration of beta cell function after gastric bypass in individuals with type 2 diabetes requires enteric stimulation. However, beta cell function in response to intravenous glucose stimulus remains severely impaired, even in individuals in full clinical diabetes remission. The permanent impairment of the beta cell may explain diabetes relapse years after surgery.

Effects of Laparoscopic Sleeve Gastrectomy on Central Obesity and Metabolic Syndrome in Indian Adults- A Prospective Study

INTRODUCTION

Increasing incidence of obesity in Indian population has led to an exponential rise in the number of bariatric operations performed annually. Laparoscopic Sleeve Gastrectomy (LSG) has been proposed to cause rapid remission of Type 2 Diabetes Melitus (T2DM) and metabolic syndrome in a weight loss independent manner.

AIM

To evaluate the effects of LSG on metabolic syndrome and central obesity in morbidly and severely obese Indian adults. Material and Methods: Study was conducted on 91 morbidly obese [Body Mass Index (BMI)>40 kg/m2] and severely obese (BMI>35 kg/m2) individuals who were suffering from diabetes, hypertension or dyslipidemia. The patients were followed up for six months and the trends of glycaemic control, mean blood pressure, lipid profile, weight loss parameters and changes in parameters of central obesity were studied.

RESULTS

Weight loss was significant at three months postsurgery and was sustained through six months. There was significant improvement in glycaemic control leading to reduction in need for oral hypoglycaemic agents or insulin in majority of them and even discontinuation of these medications in few patients. Hypertension and dyslipidemia also showed an improving trend through six months postsurgery. There was a significant impact on reduction of central obesity in these patients as marked by significant reduction in waist to hip ratio.

CONCLUSION

LSG produces sustainable weight loss with significant improvement in glycaemic status and control of metabolic syndrome in severe to morbidly obese patients. LSG is also efficacious in reducing central obesity in Indian population which is a major depressive ailment amongst obese individuals.

Bariatric Surgery: Pathophysiology and Outcomes

Diabetes mellitus and obesity are closely interrelated and pose a major burden on health care in terms of morbidity and mortality. Weight loss has favorable metabolic benefits for glycemic control and improvement of metabolic syndrome. Bariatric surgery (BS) is the most effective treatment for weight loss with durable results as compared to lifestyle modification. BS procedures have been associated with significant reduction in abdominal obesity, metabolic syndrome components, and glycemic control requiring fewer medications. Long-term risks of surgery include nutritional deficiencies, osteoporosis, bone fractures, and hyperinsulinemic hypoglycemia, which need to be carefully balanced with metabolic benefits for individual patients.

Bariatric surgery in managing diabetes mellitus

PURPOSE OF REVIEW

Obesity is a worldwide epidemic, having profound effects on Western populations. Bariatric surgery has long been employed to treat obesity and its related comorbidities. Over time, researchers have amassed significant data to support bariatric surgery in the pursuit of treating diabetes mellitus. This review serves to introduce the most recent findings and their relation to the various bariatric surgical options as bariatric surgery will continue to cement itself in the treatment paradigm of diabetes mellitus.

RECENT FINDINGS

Numerous studies performed in the past 10 years have demonstrated the improvement or cessation of diabetes with bariatric surgical intervention. In comparing the vertical sleeve gastrectomy and Roux-en-Y gastric bypass, data demonstrate a more beneficial response of diabetes to the Roux-en-Y gastric bypass, and an even further exaggerated response with the biliopancreatic diversion/duodenal switch. The benefit has long been established, but what causes the improvement in diabetes mellitus after bariatric surgery? Recent data suggest a decrease in circulating bile salts as well as changes to inflammatory markers and circulating cytokines. Furthermore, tailoring of existing surgical procedures has led to the development of the SIPS procedure, and its benefit is demonstrated in bypassing a large portion of intestine while eliminating an enteroenterostomy, helping to reduce short gut syndrome and resultant diarrhea.

SUMMARY

The surgical climate within the bariatric field is changing and will continue to do so in the future. As the understanding of the causes or mechanisms in which bariatric surgery improves metabolic disorders becomes more evident, the process of individualizing care for specific patients will become more prevalent.

Update on the treatment of type 2 diabetes mellitus

To achieve good metabolic control in diabetes and keep long term, a combination of changes in lifestyle and pharmacological treatment is necessary. Achieving near-normal glycated hemoglobin significantly, decreases risk of macrovascular and microvascular complications. At present there are different treatments, both oral and injectable, available for the treatment of type 2 diabetes mellitus (T2DM). Treatment algorithms designed to reduce the development or progression of the complications of diabetes emphasizes the need for good glycaemic control. The aim of this review is to perform an update on the benefits and limitations of different drugs, both current and future, for the treatment of T2DM. Initial intervention should focus on lifestyle changes. Moreover, changes in lifestyle have proven to be beneficial, but for many patients is a complication keep long term. Physicians should be familiar with the different types of existing drugs for the treatment of diabetes and select the most effective, safe and better tolerated by patients. Metformin remains the first choice of treatment for most patients. Other alternative or second-line treatment options should be individualized depending on the characteristics of each patient. This article reviews the treatments available for patients with T2DM, with an emphasis on agents introduced within the last decade.

Sodium-glucose co-transporter-2 inhibitors and dipeptidyl peptidase-4 inhibitors combination therapy in type 2 diabetes: A systematic review of current evidence

As type 2 diabetes mellitus (T2DM) is a chronic and progressive disease with multiple pathophysiologic defects, no single anti-diabetic agent can tackle all these multi-factorial pathways. Consequently, multiple agents working through the different mechanisms will be required for the optimal glycemic control. Moreover, the combination therapies of different anti-diabetic agents may complement their actions and possibly act synergistic. Furthermore, these combinations could possess the additional properties to counter their undesired physiological compensatory response. Sodium-glucose co-transporter-2 inhibitors (SGLT-2I) are newly emerging class of drugs, with a great potential to reduce glucose effectively with an additional quality of lowering cardiovascular events as demonstrated very recently by one of the agents of this class. However, increase in endogenous glucose production (EGP) from the liver, either due to the increase in glucagon or compensatory response to glucosuria can offset the glucose-lowering potential of SGLT-2I. Interestingly, another class of drugs such as dipeptidyl peptidase-4 inhibitors (DPP-4I) effectively decrease glucagon and reduce EGP. In light of these findings, combination therapies with SGLT-2I and DPP-4I are particularly appealing and are expected to produce a synergistic effect. Preclinical studies of combination therapies with DPP-4I and SGLT-2I have already demonstrated a significant lowering of hemoglobin A1c potential and human studies also find no drug-drug interaction between these agents. This article aims to systematically review the efficacy and safety of combination therapy of SGLT-2I and DPP-4I in T2DM.