Evaluation of insulin resistance improvement after laparoscopic sleeve gastrectomy or gastric bypass surgery with HOMA-IR

The role of bariatric surgery on beta-cell function and insulin resistance in patients with nonalcoholic fatty liver disease and steatohepatitis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) and steatohepatitis (NASH) are strongly associated with obesity, metabolic syndrome, and insulin resistance (IR).

OBJECTIVE

The aim of this study was to investigate the effects of metabolic surgery on pancreatic beta cell function and IR in patients with obesity and NAFLD.

SETTING

University Hospital, Germany.

METHODS

Liver biopsies were taken intraoperatively from 112 patients undergoing sleeve gastrectomy (n = 68) or Roux-en-Y gastric bypass (n = 44) and analyzed histologically for the presence of simple steatosis (NAFL) or NASH. Clinical and biochemical parameters were collected over up to 2 years. Beta cell function and IR were assessed using the homeostasis model assessment of beta-cell function (HOMA2-%B) and insulin resistance (HOMA2-IR) index.

RESULTS

NASH was present in 53.6% (n = 60) of the patients and NAFL in 25.9% (n = 29). Liver enzymes, adiponectin/leptin ratio, triglycerides, and HbA1C were improved at 6 months, 1, and 2 years after surgery. HOMA2-IR was significantly lower in patients without NAFLD while HOMA2-IR did not differ between patients with NAFL and/or NASH. HOMA2-%B was highest in the NAFLD group and lowest in patients with NASH. While there was no change in HOMA2-%B and HOMA2-IR in the No-NAFLD group, HOMA2-%B decreased and IR improved in the NAFL and NASH groups.

CONCLUSION

Insufficient compensatory beta-cell function may contribute to the progression from NAFL alongside with IR to NASH. Our findings suggest that bariatric surgery decreases IR while at the same time reducing compensatory insulin oversecretion. These results are associated with beneficial changes in adipose tissue function after bariatric surgery.

Change in Adipokines and Gastrointestinal Hormones After Bariatric Surgery: a Meta-analysis

PURPOSE

The study aimed to perform a meta-analysis about the change in adipokines and gastrointestinal hormones after bariatric surgery in patients with obesity.

MATERIALS AND METHODS

We searched the Cochrane Central Register of Controlled Trials, EMBASE, and PubMed for related articles and used Review Manager 5.4 for data aggregation. Sensitivity and subgroup analysis were also conducted when feasible.

RESULTS

As a result, 95 articles involving 6232 patients were included in the meta-analysis. After bariatric surgery, the levels of leptin, ghrelin, C-reactive protein (CRP), interleukin-6 (IL-6), high-sensitivity C-reactive protein (Hs-CRP), tumor necrosis, factor-α (TNF-α), and interleukin-1β (IL-1β) reduced, while adiponectin, glucagon-like peptide-1 (GLP-1), and peptide YY (PYY) levels increased significantly. Subgroup analysis indicated that there was a more significant reduction in leptin level with a longer follow-up time. OAGB had a greater effect on increasing adiponectin level compared with other procedures. SG procedure would bring about reduced ghrelin, while BPD resulted in increased ghrelin. Meta-regression analysis found that publication year, study design, number of patients, preoperative age, preoperative BMI, and quality assessment score were not significantly related to change in leptin, adiponectin, and ghrelin levels.

CONCLUSION

Bariatric surgery was associated with a significant decrease in leptin, ghrelin, CRP, IL-6, Hs-CRP, TNF-α, and IL-1β, as well as increase in adiponectin, GLP-1, and PYY levels.

Retrospective Comparison of SADI-S Versus RYGB in Chinese with Diabetes and BMI< 35kg/m2: a Propensity Score Adjustment Analysis

BACKGROUND

As a modification of the duodenal switch (DS), single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) has recently become very popular and is successful for weight loss and T2DM remission. However, current studies have been mostly aimed at patients with severe obesity.

OBJECTIVES

In this study, we firstly compare primary SADI-S to the Roux-en-Y gastric bypass (RYGB) in Chinese with diabetes and BMI< 35 kg/m2.

METHODS

Using a propensity score (PS) matching analysis, we analyzed all patients with diabetes and BMI< 35 kg/m2 who underwent primary SADI-S or RYGB. All surgeries were conducted by a single surgeon at a Chinese center from June 2017 to January 2019.

RESULTS

Twenty-six patients who underwent SADI-S and 65 patients who underwent RYGB were included in our analysis. Of these, 26 (100%) of patients in the SADI-S group and 43 (66%) of patients in the RYGB group completed the 24-month follow-up. No severe perioperative complication was observed in either group. There was a statistically higher percentage of total weight loss with SADI-S at the 2-year follow-up when compared to RYGB (p = 0.017 after PS correction). After PS adjustment, 76.5% of patients in the SADI-S group and 82.4% of patients in the RYGB group achieved complete remission of T2DM (p = 1.000). Nutritional outcomes were similar in the two groups.

CONCLUSION

In Chinese with diabetes and BMI< 35 kg/m2, with comparable T2DM remission and nutritional outcomes, primary SADI-S allows for better weight loss than RYGB. Compared with RYGB, SADI-S is also a safe, effective, and feasible treatment for these patients.

Determinants of type 2 diabetes remission after bariatric surgery in obese Japanese patients: a retrospective cohort study

Objective

Bariatric surgery (BS) improves glycemic control in type 2 diabetes; however, some patients show insufficient improvement. Understanding the pathophysiology of type 2 diabetes in obese patients can facilitate appropriate treatment for type 2 diabetes after BS. The homeostatic model assessment (HOMA) 2 enables the calculation of the values from C-peptide data and evaluation of insulin users. We aimed to evaluate the pathophysiology of type 2 diabetes using pre- and postoperative parameters and HOMA2 in obese patients who underwent BS.

Methods

We retrospectively reviewed data from 45 obese patients with type 2 diabetes who underwent BS. They were followed-up for 12 months. The relationship between the HOMA2 score and complete remission (CR) of type 2 diabetes after BS was analyzed. Patients with and without CR were assigned to the CR and non-CR groups, respectively. Multiple regression analysis was used to identify factors associated with improvement in type 2 diabetes after BS.

Results

BS significantly improved body weight and glucose metabolism. The preoperative glycosylated hemoglobin A1c level and insulin secretion (HOMA2-%B) significantly differed between the CR and non-CR groups. Postoperative weight reduction and improved insulin sensitivity correlated significantly with CR; multiple regression showed that the preoperative HOMA 2-%B independently predicted CR of type 2 diabetes after BS.

Conclusion

Preoperative insulin secretion, improvement in insulin sensitivity, and weight reduction after BS are related to CR of type 2 diabetes after BS. The results better reveal the pathophysiology of and treatment for type 2 diabetes in obese patients who undergo BS.

Glucose Tolerance after Pancreatectomy: A Prospective Observational Follow-Up Study of Pancreaticoduodenectomy and Distal Pancreatectomy

BACKGROUND

Effects of pancreatectomy on glucose tolerance have not been clarified, and evidence regarding the difference in postoperative glucose tolerance between pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) is lacking.

STUDY DESIGN

This prospective, single-center observational study analyzed 40 patients undergoing PD and 29 patients undergoing DP (Clinical trial registry number UMIN000008122). Glucose tolerance, including insulin secretion (Δ C-peptide immunoreactivity, ΔCPR) and insulin resistance (homeostasis model assessment of insulin resistance, HOMA-IR) were assessed before and 1 month after pancreatectomy using the oral glucose tolerance test (OGTT) and glucagon stimulation test. We assessed long-term hemoglobin A1c (HbA1c) levels in patients, with a follow-up time of 3 years.

RESULTS

Percentages of patients diagnosed with abnormal OGTT decreased after PD (from 12 [30%] to 7 [17.5%] of 40 patients, p = 0.096); however, they increased after DP (from 4 [13.8%] to 8 [27.6%] of 29 patients, p = 0.103), although the changes were not statistically significant. ΔCPR decreased after both PD (from 3.2 to 1.0 ng/mL, p < 0.001) and DP (from 3.3 to 1.8 ng/mL, p < 0.001). HOMA-IR decreased after PD (from 1.10 to 0.68, p < 0.001), but did not change after DP (1.10 and 1.07, p = 0.42). Median HbA1c level was higher after DP than after PD for up to 3 years, but the differences were not statistically significant.

CONCLUSIONS

In comparisons of pre- and 1 month post-pancreatectomy data, glucose tolerance showed improvement after PD, whereas it worsened after DP. Insulin secretion decreased after both PD and DP. Insulin resistance improved after PD, but did not change after DP. Further studies are warranted to clarify mechanisms of improved insulin resistance after PD.

Preintervention Clinical Determinants and Measured β-Cell Function As Predictors of Type 2 Diabetes Remission After Roux-en-Y Gastric Bypass Surgery

BACKGROUND

Bariatric surgery results in improved glycemic control in individuals with type 2 diabetes. Single and clusters of clinical determinants have been identified as presurgery predictors of postsurgery diabetes remission. Our goal was to assess whether the addition of measured preoperative β-cell function would improve established clinical models of prediction of diabetes remission.

RESEARCH DESIGN AND METHODS

Presurgery clinical characteristics, metabolic markers, and β-cell function after oral and intravenous (IV) glucose challenges were assessed in 73 individuals with severe obesity and type 2 diabetes and again 1 year after gastric bypass surgery. Single and multivariate analyses were conducted with preoperative variables to determine the best predictive models of remission.

RESULTS

Presurgery β-cell glucose sensitivity, a surrogate of β-cell function, was negatively correlated with known diabetes duration, HbA1c, insulin use, and the diabetes remission scores DiaRem and advanced (Ad)-DiaRem (all P < 0.001). Measured β-cell function after oral glucose was 1.6-fold greater than after the IV glucose challenge and more strongly correlated with preoperative clinical and metabolic characteristics. The addition of preoperative β-cell function to clinical models containing well-defined diabetes remission scores did not improve the model's ability to predict diabetes remission after Roux-en-Y gastric bypass.

CONCLUSIONS

The addition of measured β-cell function does not add predictive value to defined clinical models of diabetes remission 1 year after surgical weight loss.

Evaluation of Lipoprotein Profile and Residual Risk Three Years After Bariatric Surgery

INTRODUCTION

Obesity is a chronic disease associated with other comorbidities, including atherogenic dyslipidemia (AD). Bariatric surgery (BS) has shown to reduce cardiovascular risk (CVR) by achieving a significant weight reduction and improving the lipid profile. Different surgical techniques may have a different effect on the lipoprotein profile.

PURPOSE

To evaluate the lipid profile at 3 years after BS according to the surgical technique used and to determine which variables predict variation in the lipid profile at 3 years after BS.

METHODS

Retrospective observational study of 206 patients who underwent BS between 2010 and 2019. We analyzed the variation of lipid parameters in the 3 years of follow-up according to the surgical technique, including a group analysis of patients according to whether they had dyslipidemia and whether they were treated or untreated and determined which variables predict variation in the lipid profile at 3 years after BS.

RESULTS

There was a significant increase in high-density lipoprotein cholesterol (HDL-c) with sleeve gastrectomy (SG) and a significant decrease in total cholesterol (TC), LDL-cholesterol (LDL-c), non-HDL, and LDL/non-HDL with biliopancreatic diversion (BPD). Variables predicting lipid profile variation were surgical technique and pre-surgery lipoprotein level.

CONCLUSIONS

Malabsorptive techniques achieve a greater decrease in TC and LDL-c throughout follow-up and could also improve residual cardiovascular risk (non-HDL and LDL/non-HDL). The type of surgical technique and the presurgery lipid profile predict variation after 3 years of BS.

Remission of Type 2 Diabetes and Sleeve Gastrectomy in Morbid Obesity: a Comparative Systematic Review and Meta-analysis

BACKGROUND

The sleeve gastrectomy (SG) has gained popularity which has resulted in a rising number of patients with T2DM to undergo this procedure. This systematic review and meta-analysis aimed to compare the long-term effects of SG on T2DM remission with remission seen after Roux-en-Y gastric bypass (RYGB) or gastric banding (GB).

METHODS

A literature search was performed in PubMed and Cochrane Library using the following search terms: 'sleeve gastrectomy', 'diabetes', 'gastric bypass' and 'gastric banding'. Studies published between January 2000 and April 2018, and with following inclusion criteria were selected for this review: BMI ≥ 35 kg/m2, age ≥ 18 years, follow-up ≥ 1 year, T2DM. Data was statistically analysed using a random-effects model and results were expressed as odds ratio with 95% confidence interval.

RESULTS

After exclusion, 35 out of an initial 748 studies, consisting of 18 138 T2DM patients, remained for inclusion. Of these patients, 2480 underwent a SG. The remaining patients underwent a RYGB (n = 10,597) or GB (n = 5061). One year postoperatively, SG patients reached significantly (OR 0.71, p = 0.003) less T2DM remission than RYGB. After stratifying for different criteria for remission, RYGB still tended to result in higher remission rates, but the difference was not statistically significant. Beyond 1 year of follow-up, the difference between RYGB and SG in terms of T2DM remission decreased. SG was superior to the GB (OR 2.17, p = 0.001) after 1 year of follow-up.

CONCLUSION

This review demonstrates important remission of T2DM following SG. Nevertheless, as remission was significantly more often observed following RYGB surgery, the latter procedure remains the gold standard for reaching T2DM remission in patients with concurrent obesity.

Higher HOMA-IR index is associated with increased excess weight loss in patients with BMI≥35kg/m2 after vertical gastrectomy

INTRODUCTION

Bariatric surgery is considered the most effective treatment for severe obesity. However, it is not clear if patients with diabetes mellitus or insulin resistance have the same response than patients without those conditions. Our objective was to evaluate association between pre-surgical HOMA-IR index and percentage of excess weight loss (EWL%) one year after bariatric surgery using sleeve gastrectomy.

METHODS

Retrospective cohort including patients ≥18 years old with BMI≥35kg/m², who underwent primary sleeve gastrectomy between 2014-2017 at the Avendaño Medical Center, Peru. Only patients with Type 2 Diabetes, Hypertension, or Dyslipidemia were included. EWL% ≥60% one year after surgery was considered satisfactory. Crude and adjusted Lineal and Poisson regression with robustness was used to assess statistical associations with EWL%.

RESULTS

Ninety-one patients were included with a median of 34 years, and 57.1% were women. 85.7% had insulin resistance as per HOMA-IR. One year after surgery, 76.9% had a satisfactory EWL%. The lineal model showed .29% less EWL% per each extra year of life (P=.019), and .93% more EWL% per each extra HOMA-IR point (P=.004). The adjusted Poisson model showed 2% lower risk of having a satisfactory EWL% per each additional year of life (P=.050), and 2% more chance of success per each additional HOMA-IR point (P=.038).

CONCLUSIONS

There was association between a higher pre-surgical HOMA-IR index and increased EWL% one year after surgery. It is possible that insulin resistance does not affect negatively sleeve gastrectomy outcomes.