Bariatric Surgery in the Treatment of Type 2 Diabetes

Multiple Beneficial Effects of Laparoscopic Sleeve Gastrectomy for Patients with Obesity, Type 2 Diabetes Mellitus, and Restrictive Ventilatory Dysfunction

BACKGROUND

Some studies have suggested that bariatric surgery improves pulmonary function in patients with obesity, but whether it alleviates pulmonary ventilation disorders in patients with obesity, type 2 diabetes mellitus (T2DM), and restrictive ventilatory dysfunction(RVD) is unclear. To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) in improving pulmonary ventilation function in patients with obesity, T2DM, and RVD.

METHODS

We studied patients with T2DM and RVD (forced vital capacity (FVC) predicted < 80%, forced expiratory volume in one second/forced vital capacity (FEV1/FVC) > 70%) who underwent LSG from March 2018 to January 2020. Baseline data was recorded and follow-up visits were made at 3, 6, 9, and 12 months after surgery to evaluate glucose, hemoglobin A1c (HbA1c), body mass index (BMI), and pulmonary ventilation function. We used multivariate analyses to assess the remission of RVD (reversion of FVC to ≥80% of the predicted value).

RESULTS

We enrolled 33 patients (mean age 46.9±5.2 years, 21 males). Two patients were lost to follow-up and another patient died. Thirty patients completed follow-up; 24 had remission of RVD (24/33, 72.7%). Multivariate Cox regression analysis showed that lower HbA1c (HR=0.35 (0.16 ~ 0.76), p=0.008), reduced waist size (0.9 (0.83 ~ 0.98), p=0.017), and shorter duration of diabetes (0.67(0.47~0.97), p=0.033) were associated with alleviation of pulmonary ventilation function.

CONCLUSIONS

LSG not only controls the body weight and T2DM; it may also relieve pulmonary ventilation dysfunction in patients with obesity, T2DM, and RVD. The waist size, duration of diabetes, and HbA1c before LSG negatively affect recovery of pulmonary ventilation dysfunction.

Genetic and Life Style Risk Factors for Recurrent Non-alcoholic Fatty Liver Disease Following Liver Transplantation

Recurrent or de novo non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) following liver transplantation (LT) is a frequent event being increasingly recognized over the last decade, but the influence of recurrent NASH on graft and patient outcomes is not yet established. Taking into consideration the long term survival of liver transplanted patients and long term complications with associated morbidity and mortality, it is important to define and minimize risk factors for recurrent NAFLD/NASH. Metabolic syndrome, obesity, dyslipidemia, diabetes mellitus are life style risk factors that can be potentially modified by various interventions and thus, decrease the risk of recurrent NAFLD/NASH. On the other hand, genetic factors like recipient and/or donor PNPLA3, TM6SF2, GCKR, MBOAT7 or ADIPOQ gene polymorphisms proved to be risk factors for recurrent NASH. Personalized interventions to influence the different metabolic disorders occurring after LT in order to minimize the risks, as well as genetic screening of donors and recipients should be performed pre-LT in order to achieve diagnosis and treatment as early as possible.

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.

Sleeve gastrectomy attenuated diabetes-related cognitive decline in diabetic rats

OBJECTIVE

To investigate the effects of sleeve gastrectomy (SG) on diabetes-related cognitive decline (DCD) in rats with diabetic mellitus (DM).

METHODS AND METHODS

Forty Wistar rats were randomly divided into control (CON) group (n=10), diabetes mellitus (DM) group (n=10), sham operation (SHAM) group (n=10) and SG group (n=10). DM model was established by high-fat diet (HFD) combined with intraperitoneal injection of streptozocin (STZ). Behavioral evaluation was given using Morris water maze test and Y-maze. In addition, PET-CT, TUNEL assay, histological analysis, transmission electron microscopy (TEM), immunohistochemistry (IHC) and Western blot analysis were used to evaluate the alleviating effects and potential mechanisms of SG on DCD in DM rats.

RESULTS

Compared with the sham group, SG induced significant improvement in the metabolic indices such as blood glucose and body weight. Besides, it could attenuate the insulin resistance compared with SHAM group. In addition, SG could improve the cognitive function of DM rats, which were featured by significant decrease in the escape latency (P<0.05), and significant increase in the time in target quadrant and platform crossings (P<0.05) compared with the SHAM group. SG induced significant elevation in the spontaneous alternation compared with SHAM group (P<0.05). Moreover, SG could improve the arrangement and biosynthesis of hippocampus neuron. Moreover, SG triggered the inhibition of apoptosis of hippocampus neurons, and Western blot analysis showed SG induced significant increase in the ratios of Bcl-2/Bax and Caspase3/cleaved Caspase 3. TEM demonstrated SG could significantly improve the microstructure of hippocampus neurons compared with the SHAM group. Western blot and IHC confirmed the significant decrease in the phosphorylation of tau at Ser404 and Ser396 sites in the SG group. Furthermore, SG activated the PI3K signaling pathway by elevating the phosphorylation of PI3K and Akt and GSK3β compared with the SHAM group.

CONCLUSION

SG attenuated the DCD in DM rats, which may be related to the activation of PI3K signaling pathway.

ACCURACY OF ELASTOGRAPHY IN THE ASSESSMENT OF REDUCTION IN LIVER STEATOSIS AND FIBROSIS IN THE EARLY POSTOPERATIVE PERIOD AFTER BARIATRIC SURGERY

BACKGROUND:

Nonalcoholic hepatic steatosis is found in most obese patients and has a strong association with metabolic syndrome. The Roux-en-Y gastric bypass and the sleeve gastrectomy are the two techniques of bariatric surgery. Patients who underwent bariatric surgery have regression of nonalcoholic steatohepatitis due to a reduction in body mass index and changes in incretin hormones.

AIMS:

This study aimed to analyze the acuity of elastography in the regression of hepatic steatosis and fibrosis in obese patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy 2 months after surgery.

METHODS:

Patients in the preoperative period of bariatric surgery underwent an anthropometric evaluation and hepatic elastography to quantify fibrosis and hepatic steatosis. Two months after surgery, the same evaluation was performed again.

RESULTS:

All 17 patients who met the inclusion criteria participated in the study. Out of this, nine underwent sleeve gastrectomy, and eight underwent Roux-en-Y gastric bypass. The Roux-en-Y gastric bypass group had lower fibrosis levels postoperatively compared to preoperatively (p=0.029, p<0.05). As for steatosis, patients who underwent Roux-en-Y gastric bypass had lower postoperative values (p=0.01, p<0.05). There was also a reduction in fibrosis postoperatively in the sleeve gastrectomy group compared to preoperatively (p=0.037, p<0.05).

CONCLUSIONS:

Elastography accurately demonstrated decreased hepatic steatosis and fibrosis in the early postoperative period of bariatric surgery. Moreover, Roux-en-Y gastric bypass and sleeve gastrectomy are suitable surgical methods to improve hepatic steatosis and fibrosis within 2 months postoperatively.

Development of bariatric/metabolic surgery in Vojvodina

The paper presents the chronological development of bariatric/metabolic surgery in Vojvodina, the region with the largest incidence of obesity in Serbia, and in which 13.2% of the population suffers from diabetes with a mortality of 15.7 / 100.000, which is one of the highest rates in Europe. Bariatric surgery began in the 1950s in the United States, with the consecutive development of various restrictive, malabsorptive, and combined procedures, which are intensified by the adoption of laparoscopic techniques. After initial, European knowledge and preparation of obese patients for surgery at the end of the 1970s, the first laparoscopic bariatric/metabolic interventions started in Vojvodina at the Clinical Center in Novi Sad in 2006. Next year, the multidisciplinary team for bariatric surgery is being prepared in Slovenia and Austria, and the first interventions are performed in 2008 at the Clinic for Thoracic Surgery of the Institute in Sremska Kamenica, in the first place - laparoscopic sleeve gastrectomy. Since then, bariatric/metabolic surgery at this Institute has been performed continuously. By establishing international cooperation, three courses were held with demonstration operations in bariatric/metabolic surgery and the participation of eminent surgeons and other experts from the country and abroad. Several bariatric surgeries were performed on children (Children's Surgery Clinic in Novi Sad), as well as in Sremska Mitrovica. Their own experience in this field has been published in the international literature and through several regional meetings dedicated to metabolic surgery.

A nonhuman primate model of vertical sleeve gastrectomy facilitates mechanistic and translational research in human obesity

The obesity epidemic significantly contributes to overall morbidity and mortality. Bariatric surgery is the gold standard treatment for obesity and metabolic dysfunction, yet the mechanisms by which it exerts metabolic benefit remain unclear. Here, we demonstrate a model of vertical sleeve gastrectomy (VSG) in nonhuman primates (NHP) that mimics the complexity and outcomes in humans. We also show that VSG confers weight loss and durable metabolic benefit, where equivalent caloric intake in shams resulted in significant weight gain following surgery. Furthermore, we show that VSG is associated with early, weight-independent increases in bile acids, short-chain fatty acids, and reduced visceral adipose tissue (VAT) inflammation with a polarization of VAT-resident immunocytes toward highly regulatory myeloid cells and Tregs. These data demonstrate that this strongly translational NHP model can be used to interrogate factors driving successful intervention to unravel the interplay between physiologic systems and improve therapies for obesity and metabolic syndrome.

Sleeve Gastrectomy Ameliorates Diabetes-Induced Cardiac Hypertrophy Correlates With the MAPK Signaling Pathway

Background: Cardiac hypertrophy as a main pathological manifestation of diabetic cardiomyopathy (DCM), is a significant complication of diabetes. Bariatric surgery has been proven to relieve DCM; however, whether it can alleviate diabetes-induced cardiac hypertrophy is undefined.

Methods: Diabetic and obese rats were performed sleeve gastrectomy (SG) after having diabetes for 16weeks. The rats were euthanized 8weeks after SG. Metabolic parameters, heart function parameters, myocardial glucose uptake, morphometric and histological changes, and the expression level of mitogen-activated protein kinases (MAPKs) were determined and compared among the control group (CON group), diabetes mellitus group (DM group), sham operation group (SHAM group), and SG group.

Results: Compared with the SHAM group, the blood glucose, body weight, insulin resistance, and other metabolic parameters were significantly improved in the SG group. There was also a marked improvement in myocardial morphometric and histological parameters after SG. Furthermore, the myocardial glucose uptake and heart function were reversed after SG. Additionally, the phosphorylation of MAPKs was inhibited after SG, including p38 MAPKs, c-Jun N-terminal kinases (JNKs), and extracellular signal-regulated kinases 1/2 (ERK1/2). The expression of DUSP6, which dephosphorylates ERK1/2, was upregulated after SG. These findings suggest that SG ameliorated diabetes-induced cardiac hypertrophy correlates with the MAPK signaling pathway.

Conclusion: These results showed that diabetes-induced cardiac hypertrophy was ameliorated after SG was closely related to the inhibition of the MAPK signaling pathway and upregulation of DUSP6. Therefore, this study provides a novel strategy for treating diabetes-induced cardiac hypertrophy.

DYNAMICS OF GLUCAGON-LIKE PEPTIDE-1 AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY IN PATIENTS WITH TYPE 2 DIABETES MELLITUS ASSOCIATIONS WITH OBESITY

Laparoscopic sleeve gastrectomy (LSG) proved to be a valuable procedure for treating obesity complicated by type 2 diabetes mellitus (T2DM). The mechanism of T2DM resolution after LSG is not yet clearly defined. The objective of the study was to investigate the effect of LSG on the secretion of GLP-1 in patients with T2DM associated with obesity. Plasma GLP-1 levels were evaluated by starvation and 15, 30, 60 and 90 min after the standard carbohydrate preload for breakfast, which included 125 ml of balanced high energy Nutricia Nutridrink Protein. Evaluations were made on the eve of the procedure, for 4 days and 3 months after the operation. In 7 patients with T2DM were diagnosed for the first time, in 3 patients with diabetic history 2 years, in 1 patient – 3.5 years and in 1 patient – 10 years. Mean glycated hemoglobin before surgery was 7.7 ± 1.6%, 3 months after LSG – 5.9 ± 0.4%. The concentration of GLP-1 in 30 minutes before surgery was 6.7 ± 0.9 ng/ml. On the 4th day after LSG, the mean level of GLP-1 was 9.6 ± 0.2 ng/ml, which statistically differed from its level in the pre-operative period, and after 3 months the mean level of GLP-1 statistically increased to 13.7 ± 0.3 ng/ml. Thus LSG leads to an early and significant increase in post-prandial secretion GLP-1 in T2DM patients associated with obesity. The rapid postoperative improvement in signs of carbohydrate metabolism indicates the importance of the incretin effect LSG in the implementation of early compensation mechanisms for T2DM and explains the metabolic activity of this operation.

One-anastomosis gastric bypass (OAGB) in patients with BMI < 30 kg/m2 and diabetes mellitus type 2 (DM2)

INTRODUCTION

type-2 diabetes mellitus (DM2) is a major health problem, as it leads to increased morbidity and mortality. Metabolic surgery has shown good results in glycemic control; however, its use has not become popular.

OBJECTIVES

to evaluate DM2 remission, as well as changes in body mass index (BMI), in overweight diabetic patients after undergoing metabolic surgery.

METHODS

a retrospective review was carried out of all patients with DM2 and BMI between 25 and 29.9 kg/m2 who underwent laparoscopic one-anastomosis gastric bypass (OAGB) as metabolic procedure between 2016 and 2019.

RESULTS

a total of 15 patients were included with a mean age of 46.6 ± 11.25 years. Mean BMI was 28.41 ± 0.94 kg/m2. Average duration was 5.4 ± 2.79 years, and presurgical fasting glucose was 288.53 ± 65.22 mg/dL. Preoperative glycated hemoglobin (HbA1c) was 9.58 ± 1.66 %. Two years after surgery HbA1c was 5.21 ± 0.26 %. The remission rate of DM2 was 100 %. All patients maintained a normal BMI range.

CONCLUSIONS

OAGB is a valid alternative for complete DM2 remission no matter if it is not accompanied by some degree of obesity, since in this case the length of the biliopancreatic limb and common channel is modified to make a less malabsorptive procedure.

Association between weight loss and reduced use of antihypertensive, hypoglycemic, psychotropic, and lipid-lowering drugs in patients undergoing bariatric surgery

Objectives: To analyze whether the weight reduction observed in bariatric surgery (Roux-en-Y gastric bypass; BGYR) is accompanied by a reduction in the use of antihypertensive, hypoglycemic, antilipidemic, and psychotropic drugs after 6 and 12 months. Methods: Longitudinal, retrospective study of 100 adult patients undergoing RYGB from May 2015 to January 2019, by laparotomy or laparoscopy. Data on age, body mass index (BMI), and the number of drugs used were recorded 6 and 12 months after surgery. Results: The mean age was 39.7 ± 9.7 years, and the majority were female (n = 78). The mean preoperative BMI was 43.7 ± 5.1 kg/m2, and the mean reduction in BMI after 6 months was 12.1 kg/m2 and 14.9 kg/m2 after 12 months. The reduction in antihypertensive drugs was 65.2% after 6 months and 96% after 12 months. The reduction in 6 months of hypoglycemic agents was 84.3%, and in 12 months, 98.3%. The average reduction in antidyslipidemic drugs was 86.7% in 6 months, and there was no record of using this medication after 12 months. Psychotropics showed a temporary reduction in use after 6 months with a return to levels close to the baseline after 1 year.There was no correlation between the variation in BMI and the use of drugs. Conclusions: there was a significant reduction in the use of drugs after 6 and 12 m, except for psychotropic drugs. The reduction in the use of drugs was not correlated with a reduction in BMI.

Bariatric Surgery and Type 2 Diabetes Remission Rates: a Retrospective Cohort Study Comparing Military Veterans and Beneficiaries

PURPOSE

The disease burden of type 2 diabetes (T2D) costs the military healthcare system an estimated $1.66 billion annually. Thirty-four percent of veterans and 28% of military beneficiaries are obese, a common feature of T2D. Bariatric surgery is a viable treatment for T2D, whether if long-term remission of T2D post-bariatric surgery occurs remains unknown. The purpose of this study was to assess differences between outcomes of veterans and military beneficiaries following bariatric surgery.

MATERIALS AND METHODS

A retrospective cohort study assessed retirees and beneficiaries diagnosed with T2D who had bariatric surgery between 2005 and 2015. Outcomes included T2D remission and vitamin and mineral deficiencies each year for 5 years post-op, analyzed via ANOVA.

RESULTS

Ninety-one patients, 46 beneficiaries and 45 retirees, were included with a mean age of 51 and 57, respectively. No significant differences between T2D remission and vitamin/mineral deficiencies 5 years post-op were found between groups. Patients with uncontrolled diabetes before surgery were less likely to achieve T2D remission for all 5 years post-op, regardless of military affiliation (p < .05).

CONCLUSION

Veterans do not have better rates of T2D remission or weight loss following bariatric surgery than other populations. Control of T2D pre-surgery is a potential clinical indicator of T2D remission success following bariatric surgery.

Predictive Model of Type 2 Diabetes Remission after Metabolic Surgery in Chinese Patients

INTRODUCTION

Metabolic surgery is an effective treatment for type 2 diabetes (T2D). At present, there is no authoritative standard for predicting postoperative T2D remission in clinical use. In general, East Asian patients with T2D have a lower body mass index and worse islet function than westerners. We aimed to look for clinical predictors of T2D remission after metabolic surgery in Chinese patients, which may provide insights for patient selection.

METHODS

Patients with T2D who underwent metabolic surgery at the Third Xiangya Hospital between October 2008 and March 2017 were enrolled. T2D remission was defined as an HbA1c level below 6.5% and an FPG concentration below 7.1 mmol/L for at least one year in the absence of antidiabetic medications.

RESULTS

(1) Independent predictors of short-term T2D remission (1-2 years) were age and C-peptide area under the curve (C-peptide AUC); independent predictors of long-term T2D remission (4-6 years) were C-peptide AUC and fasting plasma glucose (FPG). (2) The optimal cutoff value for C-peptide AUC in predicting T2D remission was 30.93 ng/ml, with a specificity of 67.3% and sensitivity of 75.8% in the short term and with a specificity of 61.9% and sensitivity of 81.5% in the long term, respectively. The areas under the ROC curves are 0.674 and 0.623 in the short term and long term, respectively. (3) We used three variables (age, C-peptide AUC, and FPG) to construct a remission prediction score (ACF), a multidimensional 9-point scale, along which greater scores indicate a better chance of T2D remission. We compared our scoring system with other reported models (ABCD, DiaRem, and IMS). The ACF scoring system had the best distribution of patients and prognostic significance according to the ROC curves.

CONCLUSION

Presurgery age, C-peptide AUC, and FPG are independent predictors of T2D remission after metabolic surgery. Among these, C-peptide AUC plays a decisive role in both short- and long-term remission prediction, and the optimal cutoff value for C-peptide AUC in predicting T2D remission was 30.93 ng/ml, with moderate predictive values. The ACF score is a simple reliable system that can predict T2D remission among Chinese patients.