Discordance in prediction for prognosis of type 2 diabetes after metabolic surgery: comparison of the ABCD, DiaRem, and individualized metabolic surgery models

Comparison of the ABCD Score's Accuracy in Predicting Remission of Type 2 Diabetes Mellitus One Year After Sleeve Gastrectomy, One Anastomosis Gastric Bypass, and Sleeve Gastrectomy with Transit Bipartition

PURPOSE

ABCD score is one of the scoring systems that predicts the probability of T2DM remission after bariatric surgery. Its success in determining T2DM remission after sleeve gastrectomy with transit bipartition (TB) has not yet been validated. The aim of this study was to evaluate the predictive value of ABCD score in TB.

MATERIALS AND METHODS

Of 438 patients with T2DM, 191 underwent sleeve gastrectomy (SG), 136 underwent one anastomosis gastric bypass (OAGB), and 111 underwent TB. Retrospective analysis of ABCD scores, 1-year postoperative remission rates, and the predictive accuracy of ABCD scores for these were conducted.

RESULTS

In the SG, OAGB, and TB groups, respectively, median ABCD scores were 7, 6, and 4, while complete remission rates were 95.3%, 84.6%, and 76.6% (p < 0.001). The area under curves (AUCs) for SG, OAGB, and TB were 0.829 (95% CI = 0.768 to 0.879, p < 0.0001), 0.801 (95% CI = 0.724 to 0.865, p < 0.0001), and 0.840 (95% CI = 0.758 to 0.902, p < 0.0001), respectively. There was no statistically significant difference between AUCs.

CONCLUSION

ABCD score predicts the probability of remission at 1-year follow-up in T2DM patients undergoing TB as accurately as in patients receiving SG or OAGB.

Metabolomics in Bariatric Surgery: Towards Identification of Mechanisms and Biomarkers of Metabolic Outcomes

Bariatric surgery has been widely performed for the treatment of obesity and type 2 diabetes. Efforts have been made to investigate the mechanisms underlying the metabolic effects achieved by bariatric surgery and to identify candidates who will benefit from this surgery. Metabolomics, which includes comprehensive profiling of metabolites in biological samples, has been utilized for various disease entities to discover pathophysiological metabolic pathways and biomarkers predicting disease progression or prognosis. Over the last decade, metabolomic studies on patients undergoing bariatric surgery have identified significant biomarkers related to metabolic effects. This review describes the significance, progress, and challenges for the future of metabolomics in the area of bariatric surgery.

External validation of predictive scores for diabetes remission after metabolic surgery

PURPOSE

Bariatric surgery has proven to be the most efficient treatment for obesity and type 2 diabetes mellitus (T2DM). Despite detailed qualification, desirable outcome after an intervention is not achieved by every patient. Various risk prediction models of diabetes remission after metabolic surgery have been established to facilitate the decision-making process. The purpose of the study is to validate the performance of available risk prediction scores for diabetes remission a year after surgical treatment and to determine the optimal model.

METHODS

A retrospective analysis comprised 252 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2009 and 2017 and completed 1-year follow-up. The literature review revealed 5 models, which were subsequently explored in our study. Each score relationship with diabetes remission was assessed using logistic regression. Discrimination was evaluated by area under the receiver operating characteristic (AUROC) curve, whereas calibration by the Hosmer-Lemeshow test and predicted versus observed remission ratio.

RESULTS

One year after surgery, 68.7% partial and 21.8% complete diabetes remission and 53.4% excessive weight loss were observed. DiaBetter demonstrated the best predictive performance (AUROC 0.81; 95% confidence interval (CI) 0.71-0.90; p-value > 0.05 in the Hosmer-Lemeshow test; predicted-to-observed ratio 1.09). The majority of models showed acceptable discrimination power. In calibration, only the DiaBetter score did not lose goodness-of-fit in all analyzed groups.

CONCLUSION

The DiaBetter score seems to be the most appropriate tool to predict diabetes remission after metabolic surgery since it presents adequate accuracy and is convenient to use in clinical practice. There are no accurate models to predict T2DM remission in a patient with advanced diabetes.

Bariatric metabolic surgery: An effective treatment of type 2 diabetes

Background:

Bariatric metabolic surgery is evolving as an option for the treatment of type 2 diabetes mellitus (T2DM) in patients with obesity and T2DM, warranting more studies on the efficacy of bariatric metabolic surgery on T2DM.

Objective:

To determine T2DM remission in patients with obesity and T2DM with up to two years follow-up after bariatric metabolic surgery.

Materials and Methods:

A retrospective review of prospectively maintained data was undertaken to identify patients who had T2DM and underwent bariatric surgery at a single centre in 2016. Data collected included age, gender, body mass index (BMI), fasting plasma glucose, haemoglobin A1c, hypertension, (HTN), Obstructive sleep apnea (OSA), initial weight and the weight at intervals of 6, 12, and 24 months. Data on the treatment of T2DM before the surgery was also collected. The criteria of the American Diabetes Association were used for the definition of T2DM remission. Only the data on patients in this study who had more than 12 months’ follow-up information was analysed.

Results:

Two hundred and eighty patients with T2DM were identified. 191 patients had more than 12 months’ follow-up information. Mean age and BMI were 49.58 ± 10.64 years and 44.03 ± 7.86 kg/m² respectively. There were 29 patients on insulin, 21 (10.9%) on insulin only and 8 (4.2%) on insulin and oral hypoglycaemic agents (OHA). One hundred and forty-six patients (76.4%) were on OHA, 134 on a single OHA and 12 on more than one OHA. Twenty-six patients (13.6%) were newly diagnosed with T2DM when they came in for bariatric metabolic surgery. One hundred and fifty-six patients (81.7%) achieved complete remission. 14 (7.3%) of these patients used to be on insulin with or without OHA and 142 (74.3%) were patients either on OHA or no OHA. There were 12 (6.4%) patients in partial remission. There was improvement in 23 (12.04%). Eight patients were on insulin but at lower doses and 15 were on a single OHA. The average percentage of total weight loss at 6, 12 and 24 months was 29.7%, 33.9% and 35.6% respectively. Patients with shorter duration of T2DM had higher remission rates as compared to patients with longer duration (r = −0.874, P = 0.001). There was also a significant resolution of HTN (81.8%) and OSA (82.3%) after bariatric metabolic surgery.

Conclusion:

This study collaborates reports that there is significant remission of T2DM after bariatric metabolic surgery in patients with obesity and T2DM. There is a need for prospective, multi-centre, and long-term studies on bariatric metabolic surgery to treat patients with obesity and T2DM.

Review, Performance Comparison, and Validation of Models Predicting Type 2 Diabetes Remission After Bariatric Surgery in a Western European Population

PURPOSE

The majority of patients with type 2 diabetes (T2DM) achieve remission after bariatric surgery. Several models are available to preoperatively predict T2DM remission. This study compares the performance of these models in a Western population one year after surgery and explores their predictive value in comparison to a model specifically designed for our study population.

MATERIALS AND METHODS

Prediction models were retrieved using a literature search. Patients were retrospectively selected from a database of the Antwerp University Hospital. Performance of the models was assessed by determining the area under the receiver operating characteristic curve (AUROC), the accuracy, and the goodness of fit, and by comparing them to a custom-made logistic model.

RESULTS

The probability of T2DM remission was calculated using 11 predictive scoring models and 8 regression models in a cohort of 250 patients. Complete T2DM remission occurred in 64.0% of patients. The IMS score (AUROC = 0.912; accuracy = 83.6%), DiaBetter score (0.907; 82.0%), and Ad-DiaRem score (0.903; 82.8%) best predicted T2DM remission and closely approached the performance of the custom-constructed model (0.917; 84.0%). The model by Ioffe et al. (0.630; 69.2%), Umemura et al. (0.692; 71.4%), and the ABCD score (0.757; 72.8%) were the least accurate.

CONCLUSION

Most T2DM remission models reliably predicted one-year T2DM remission, with limited inter-model differences. The accuracy of most models approached that of the custom-constructed model, indicating a high predictive capability and performance in our patient cohort. To date, most models are only validated to estimate T2DM remission one year after surgery and they do not predict long-term remission.

Metabolomic Profiles Predict Diabetes Remission after Bariatric Surgery

Background: Amino acid metabolites (AAMs) have been linked to glucose homeostasis and type 2 diabetes (T2D). We investigated whether (1) baseline AAMs predict T2D remission 12 months after bariatric surgery and (2) whether AAMs are superior for predicting T2D remission postoperatively compared with existing prediction models. Methods: Among 24 participants undergoing bariatric surgery, 16 diabetes-related AAMs were quantified at baseline and postoperative 3 and 12 months. Existing prediction models included the ABCD, DiaRem, and IMS models. Results: Baseline L-dihydroxyphenylalanine (L-DOPA) (areas under receiver operating characteristic curves (AUROC), 0.92; 95% confidence interval (CI), 0.75 to 1.00) and 3-hydroxyanthranilic acid (3-HAA) (AUROC, 0.85; 95% CI, 0.67 to 1.00) better predicted T2D remission 12 months postoperatively than the ABCD model (AUROC, 0.81; 95% CI, 0.54 to 1.00), which presented the highest AUROC value among the three models. The superior prognostic performance of L-DOPA (AUROC at 3 months, 0.97; 95% CI, 0.91 to 1.00) and 3-HAA (AUROC at 3 months, 0.86; 95% CI, 0.63 to 1.00) continued until 3 months postoperatively. Conclusions: The AAM profile predicts T2D remission after bariatric surgery more effectively than the existing prediction models.

Oncometabolic surgery: Emergence and legitimacy for investigation

Studies on morbid obesity have shown remarkable improvement of diabetes in patients who have undergone bariatric operations. It was subsequently shown that these operations induce diabetes remission independent of the resultant weight loss; as a result, surgeons began to investigate whether operations for gastric cancer (GC) could have the same beneficial effect on diabetes as bariatric operations. It was then shown in multiple reports that followed that certain operations for GC were able to improve or even cure type 2 diabetes mellitus (T2DM) in GC patients. This finding gave rise to the concept of “oncometabolic surgery”, in which a patient diagnosed with both GC and T2DM undergo a single operation with the purpose of treating both diseases. With the increasing incidence of T2DM, oncometabolic surgery has the potential to improve the quality of life and even extend survival of many GC patients. However, because the GC patient population and the bariatric patient population are wildly different and because different GC operations have different properties, the effect of oncometabolic surgery must be carefully assessed and engineered in order to maximize benefit and avoid harm. This manuscript aims to summarize the findings made so far in the field of oncometabolic surgery and to provide an outlook regarding the possibility of oncometabolic surgery being incorporated into standard clinical practice.