Predicting remission of diabetes post metabolic surgery: a comparison of ABCD, diarem, and DRS scores

Predictors of diabetes remission after bariatric surgery in patients with type 2 diabetes mellitus duration ≥ 10 years: A retrospective cohort study

OBJECTIVE

Patients with type 2 diabetes mellitus (T2DM) duration ≥ 10 years often have significant β-cell failure. This study aimed to explore predictors of diabetes remission after bariatric surgery in these patients.

METHODS

Patients with T2DM duration ≥ 10 years who underwent bariatric surgery were retrospective included and followed up. Remission of diabetes was defined as an HbA1c < 6.5 % (48 mmol/mol) at least 3 months after the discontinuation of hypoglycemic drugs. An intravenous glucose tolerance test (IVGTT) was performed in patients with diabetes remission.

RESULTS

203 patients with T2DM duration ≥ 10 years were included, 59.6 % were treated with insulin before bariatric surgery. One-, two- and three-year post-surgery remission rates were 65.6 %, 53.8 % and 41.9 %, respectively (∼10 % decrease/year). Cox regression analysis revealed that the odds of remission at one-year post-bariatric surgery were most strongly associated with β-cell function (HR 1.20, 95 % CI 1.03-1.40) and percentage of total weight loss (%TWL) (HR 1.04, 95 % CI 1.01-1.07). The first-phase insulin secretion peak was approximately 5-8 folds of the fasting insulin level in 50 patients with diabetes remission.

CONCLUSIONS

%TWL and β-cell function are significantly associated with diabetes remission after bariatric surgery in long-duration T2DM patients, with restored first-phase insulin secretion still observed.

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.

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.

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.

Metabolic surgery in patients with diabesity: A review of the historical backgrounds and scoring systems

Diabesity is a modern term that describes the coexistence of adverse health effects of diabetes mellitus and obesity and indicates a causal pathophysiological relationship between the two phenomena. The progression of diabesity leads to a deterioration of multiple organs and systems. Effective intervention for patients with diabesity must include optimal obesity therapy to prevent secondary complications. Metabolic surgery is the most effective and sustainable therapy for severe obesity and the elimination or prevention of many associated diseases, including type 2 diabetes mellitus, hypertension, sleep apnea, heart disease, and certain cancers. This review provides an up-to-date overview of surgical interventions for obesity, particularly the development of metabolic surgery. It evaluates different scoring systems for evidence-based selection of metabolic surgery based on disease severity. We reviewed different predictive scoring systems for better evidence-based selection of the best metabolic surgery for patients with diabesity. We found that medication type, fasting insulin level, and C-peptide influence the outcomes of different types of metabolic surgery and heterogeneous remission rates. There are different predictive scoring systems for evidence-based selection of the best metabolic surgery, either sleeve or mini-bypass, that will ensure the highest chance of diabetes remission. Using the metabolic score calculator is a useful tool to help medical specialists determine the optimal treatment strategy for a particular patient. More research is needed before we can agree on the ideal bariatric procedure that offers the highest chance of remission with the lowest incidence of hypoglycemia.

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.

Transcriptome Changes and Metabolic Outcomes After Bariatric Surgery in Adults With Obesity and Type 2 Diabetes

Context

Bariatric surgery has been shown to be effective in inducing complete remission of type 2 diabetes in adults with obesity. However, its efficacy in achieving complete diabetes remission remains variable and difficult to predict before surgery.

Objective

We aimed to characterize bariatric surgery-induced transcriptome changes associated with diabetes remission and the predictive role of the baseline transcriptome.

Methods

We performed a whole-genome microarray in peripheral mononuclear cells at baseline (before surgery) and 2 and 12 months after bariatric surgery in a prospective cohort of 26 adults with obesity and type 2 diabetes. We applied machine learning to the baseline transcriptome to identify genes that predict metabolic outcomes. We validated the microarray expression profile using a real-time polymerase chain reaction.

Results

Sixteen patients entered diabetes remission at 12 months and 10 did not. The gene-expression analysis showed similarities and differences between responders and nonresponders. The difference included the expression of critical genes (SKT4, SIRT1, and TNF superfamily), metabolic and signaling pathways (Hippo, Sirtuin, ARE-mediated messenger RNA degradation, MSP-RON, and Huntington), and predicted biological functions (β-cell growth and proliferation, insulin and glucose metabolism, energy balance, inflammation, and neurodegeneration). Modeling the baseline transcriptome identified 10 genes that could hypothetically predict the metabolic outcome before bariatric surgery.

Conclusion

The changes in the transcriptome after bariatric surgery distinguish patients in whom diabetes enters complete remission from those who do not. The baseline transcriptome can contribute to the prediction of bariatric surgery-induced diabetes remission preoperatively.

Remission of Type II Diabetes Mellitus 1-Year Postoperative Following One Anastomosis Gastric Bypass in Correlation with ABCD, DiaRem, and DRS Scores

BACKGROUND

Diabetes mellitus (DM) is a debilitating chronic illness. Roux en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) present a potential solution to type II DM. Several scoring systems predict DM remission as ABCD score, DiaRem score, and diabetes remission score (DRS).

STUDY DESIGN

This was a retrospective study that included 138 patients with DM and underwent OAGB. BMI, HbA1C, insulin, and oral hypoglycemics need were recorded pre- and postoperatively with calculation of ABCD, DiaRem, and DRS scores. Effects of OAGB on DM were observed and correlated with the scoring systems to detect their sensitivity and specificity.

RESULTS

Age, preoperative, and postoperative BMI were 47.38 ± 7.632, 45.096 ± 4.465, and 31.173 ± 3.799 respectively. The preoperative and stimulated C-peptides were 3.357 ± 0.995 and 4.158 ± 0.897 ng/ml respectively. The preoperative and postoperative HbA1C were 7.396 ± 0.743% and 6.564 ± 0.621% respectively. Patients with complete remission were 32 patients (23.2%) and with partial remission were 46 patients (33.3%) adding to 56.5% considered in remission. There was significant decrease of BMI, HbA1C, insulin, and oral hypoglycemic use postoperatively. Receiver operator characteristics (ROC) curve showed that ABCD, DiaRem, and DRS scores had AUC of 0.853 with cut-off > 5, 0.921 with cut-off ≤ 8, and 0.805 with cut-off ≤ 8 respectively. The DiaRem score had the highest AUC followed by ABCD score then DRS score.

CONCLUSION

OAGB significantly reduced BMI and HbA1C values 1 year postoperatively with 56.5% DM remission. DiaRem score had more remission predictive value following OAGB than ABCD and DRS scores especially when ≤ 8 with 90.6% sensitivity and 83% specificity.

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.

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.

Predictors of Type 2 Diabetes Mellitus Remission After Metabolic Surgery in Asian Patients with a BMI < 32.5 kg/m2

BACKGROUND

Metabolic surgery is an effective treatment for type 2 diabetes mellitus (T2DM) in patients with obesity. However, the efficacy in patients with body mass index (BMI) < 32.5 kg/m², especially in Asian populations, has not been widely reported, and there are few studies on the prediction of diabetes remission.

METHODS

We evaluated 112 patients with T2DM who underwent metabolic surgery between October 2008 and November 2019. The basic data of the patients were collected, and clinical variables were measured at 6 months, 1 year, and 2 years after metabolic surgery. Four independent predictors of surgical outcomes were identified to construct the prediction score.

RESULTS

Diabetes remission occurred for 38 of the 112 patients. Ninety patients underwent Roux-en-Y gastric bypass, while the remaining 22 patients underwent sleeve gastrectomy. Weight, glucose, and lipid metabolism parameters were improved significantly after metabolic surgery. Age, BMI, insulin use, and duration were independent predictors of T2DM remission. The above four factors were defined with scores and developed ABID (age, BMI, insulin use, duration) scoring system. Patients with greater ABID scores had a greater probability of diabetes remission (from 0% at score 0 to 100% at score 4).

CONCLUSIONS

The ABID score is a simple and easy-to-implement prediction score system of diabetes remission after metabolic surgery for T2DM patients with a BMI < 32.5 kg/m².

Identification of adipose tissue-related predictors of the reduction in cardiovascular risk induced by metabolic surgery

Objectives

We aimed to determine whether parameters associated with adipose tissue (adipocyte density and the circulating concentrations of markers of adipose tissue pathology) predict cardiovascular risk (CVR) modification after metabolic surgery (MS).

Methods

We performed a case–control study of patients with morbid obesity who were candidates for MS. CVR was defined using flow-mediated dilation (FMD) and carotid intima media thickness (CIMT), which were measured during the 9 months following MS. Subgroups of CVR reduction were defined using the following cut-offs: CIMT 10% and/or a two-fold increase in FMD.

Results

We studied 40 patients with morbid obesity (mean age 44.5 years, 75% women, mean body mass index 46.4 kg/m²) and high prevalences of the metabolically unhealthy obesity phenotype, hypertension, and diabetes mellitus. A significant reduction in CVR was associated with lower vascular endothelial growth factor-A concentration (6.20 vs. 1.59 pg/mL, respectively), low adipocyte density in visceral adipose tissue (100 vs. 80 cells/field), low infiltration with CD68+ cells (18 vs. 8 cells/field) and higher concentrations of lipid peroxidation markers and malondialdehyde (313.7 vs. 405.7 ng/mL).

Conclusion

The characteristics of adipose tissue and the circulating concentrations of markers of adipose pathology might represent useful predictors of the reduction in CVR following MS.

Clinical trial registration number: NCT0356198 (https://clinicaltrials.gov)

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB)

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.

Comparative Effectiveness of Vertical Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass for Diabetes Treatment: A Claims-based Cohort Study

OBJECTIVE

The aim of the study was to compare diabetes outcomes following vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB).

BACKGROUND

There are few comparative studies on diabetes outcomes after VSG and RYGB.

METHODS

We used a US-wide commercial insurance claims database to identify adults with diabetes undergoing VSG or RYGB in 2010 to 2016. We matched patients on baseline insulin use, total diabetes medication burden, age, presence of diabetes complications, and follow-up duration, and used adjusted Cox proportional hazards models to compare diabetes medication discontinuation between procedures. We used difference-in-differences analyses to compare changes in medication use intensity up to 2 years after surgery.

RESULTS

The matched cohort included 1111 VSG and 922 RYGB patients: 16% were younger than 40 years, 11% were 60 years or older, 67% were women, 67% had a body mass index of 40 kg/m2 or higher, and 23% were on insulin at the time of surgery. Thirteen percent were lost to follow-up at 1 year, and 30% at 2 years after surgery. Patients with VSG were less likely than matched RYGB patients to discontinue all diabetes medications (hazard ratio 0.80, 95% confidence interval 0.72-0.88). Although both groups had substantial decreases in medication use after surgery, RYGB patients had an 86% (32%, 140%) lower total diabetes medication dose than VSG by the second half of postoperative year 2.

CONCLUSIONS

In a large claims-based, nationwide cohort of bariatric patients with diabetes, those undergoing RYGB were more likely to come off all medications than those undergoing VSG. Patients with diabetes should consider this potential benefit of RYGB when making informed decisions about obesity treatments.

C-peptide level as predictor of type 2 diabetes remission and body composition changes in non-diabetic and diabetic patients after Roux-en-Y gastric bypass

OBJECTIVES

Several predictors of type 2 diabetes mellitus (T2DM) remission after metabolic surgery have been proposed and used to develop predictive scores. These scores may not be reproducible in diverse geographic regions with different baseline characteristics. This study aimed to identify predictive factors associated with T2DM remission after Roux-en-Y gastric bypass (RYGB) in patients with severe obesity. We hypothesized that the body composition alterations induced by bariatric surgery could also contribute to diabetes remission.

METHODS

We retrospectively evaluated 100 patients with severe obesity and T2DM who underwent RYGB between 2014 and 2016 for preoperative factors (age, diabetes duration, insulin use, HbA1c, C-peptide plasma level, and basal insulinemia) to identify predictors of T2DM remission (glycemia<126 mg/dL and/or HbA1c<6.5%) at 3 years postoperatively. The potential preoperative predictors were prospectively applied to 20 other patients with obesity and T2DM who underwent RYGB for validation. In addition, 81 patients with severe obesity (33 with T2DM) underwent body composition evaluations by bioelectrical impedance analysis (InBody 770®) 1 year after RYGB for comparison of body composition changes between patients with and those without T2DM.

RESULTS

The retrospective analysis identified only a C-peptide level >3 ng/dL as a positive predictor of 3-year postoperative diabetes remission, which was validated in the prospective phase. There was a significant difference in the postoperative body composition changes between non-diabetic and diabetic patients only in trunk mass.

CONCLUSION

Preoperative C-peptide levels can be useful for predicting T2DM remission after RYGB. Trunk mass is the most important difference in postoperative body composition changes between non-diabetic and diabetic patients.

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.

Comparison of Preoperative Remission Scores and Diabetes Duration Alone as Predictors of Durable Type 2 Diabetes Remission and Risk of Diabetes Complications After Bariatric Surgery: A Post Hoc Analysis of Participants From the Swedish Obese Subjects Study

OBJECTIVE

Bariatric surgery is associated with diabetes remission and prevention of diabetes-related complications. The ABCD, DiaRem, Ad-DiaRem, DiaBetter, and individualized metabolic surgery scores were developed to predict short- to medium-term diabetes remission after bariatric surgery. However, they have not been tested for predicting durable remission nor the risk of diabetes complications, nor compared with diabetes duration alone.

RESEARCH DESIGN AND METHODS

We identified 363 individuals from the surgically treated group in the prospective Swedish Obese Subjects study with preoperative type 2 diabetes and for whom data (preoperative age, BMI, C-peptide, HbA_1c, oral diabetes medications, insulin use, and diabetes duration) were available for calculation of remission scores. Partial remission (after 2 and 10 years) was defined as blood glucose <6.1 mmol/L or HbA_1c <6.5% (48 mmol/mol) and no diabetes medication. Information on diabetes complications (at baseline and over 15 years of follow-up) was obtained from national health registers. Discrimination was evaluated by area under receiver operating characteristic curves (AUROCs).

RESULTS

For 2-year diabetes remission, AUROCs were between 0.79 and 0.88 for remission scores and 0.84 for diabetes duration alone. After 10 years, the predictive ability of scores decreased markedly (AUROCs between 0.70 and 0.76), and no score had higher predictive capacity than diabetes duration alone (AUROC = 0.73). For development of microvascular and macrovascular diabetes complications over 15 years, AUROCs for remission scores were 0.70-0.80 and 0.62-0.71, respectively, and AUROCs for diabetes duration alone were 0.77 and 0.66, respectively.

CONCLUSIONS

Remission scores and diabetes duration are good predictors of short-term diabetes remission. However, for durable remission and risk of complications, remission scores and diabetes duration alone have limited predictive ability.

Defining remission of type 2 diabetes in research studies: A systematic scoping review

BACKGROUND

Remission has been identified as a top priority by people with type 2 diabetes. Remission is commonly used as an outcome in research studies; however, a widely accepted definition of remission of type 2 diabetes is lacking. A report on defining remission was published (but not formally endorsed) in Diabetes Care, an American Diabetes Association (ADA) journal. This Diabetes Care report remains widely used. It was the first to suggest 3 components necessary to define the presence of remission: (1) absence of glucose-lowering therapy (GLT); (2) normoglycaemia; and (3) for duration ≥1 year. Our aim is to systematically review how remission of type 2 diabetes has been defined by observational and interventional studies since publication of the 2009 report.

METHODS AND FINDINGS

Four databases (MEDLINE, EMBASE, Cochrane Library, and CINAHL) were searched for studies published from 1 September 2009 to 18 July 2020 involving at least 100 participants with type 2 diabetes in their remission analysis, which examined an outcome of type 2 diabetes remission in adults ≥18 years and which had been published in English since 2009. Remission definitions were extracted and categorised by glucose-lowering therapy, glycaemic thresholds, and duration. A total of 8,966 titles/abstracts were screened, and 178 studies (165 observational and 13 interventional) from 33 countries were included. These contributed 266 definitions, of which 96 were unique. The 2009 report was referenced in 121 (45%) definitions. In total, 247 (93%) definitions required the absence of GLT, and 232 (87%) definitions specified numeric glycaemic thresholds. The most frequently used threshold was HbA1c<42 mmol/mol (6.0%) in 47 (20%) definitions. Time was frequently omitted. In this study, a total of 104 (39%) definitions defined time as a duration. The main limitations of this systematic review lie in the restriction to published studies written in English with sample sizes of over 100. Grey literature was not included in the search.

CONCLUSIONS

We found that there is substantial heterogeneity in the definition of type 2 diabetes remission in research studies published since 2009, at least partly reflecting ambiguity in the 2009 report. This complicates interpretation of previous research on remission of type 2 diabetes and the implications for people with type 2 diabetes. Any new consensus definition of remission should include unambiguous glycaemic thresholds and emphasise duration. Until an international consensus is reached, studies describing remission should clearly define all 3 components of remission.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019144619.

Factors associated with complete and partial remission, improvement, or unchanged diabetes status of obese adults 1 year after sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) achieves type 2 diabetes (T2D) remission to various extents, and reasons for such variations are unknown.

OBJECTIVES

We assessed patients' characteristics associated with T2D remission 1 year post SG.

SETTING

University hospital.

METHODS

Retrospective study of 230 T2D patients (18-64 yr) who underwent SG at our institution. We examined pre- and postoperative demographic, anthropometric, biochemical, and clinical characteristics associated with T2D complete remission, partial remission, improvement, or unchanged status. Independent predictors of T2D complete remission were assessed by binary logistic regression and then included in 7 predictive models. Logistic regression assessed the pre- and postoperative predictors of T2D complete remission and their predictive performance was measured with the area under the curve of the receiver operating characteristic curve.

RESULTS

A total of 230 patients were included in the study, females comprised 69%, and mean age was 45.66 ± 8.84 years. Mean preoperative weight and body mass index were 115.69 ± 20.76 kg and 43.53 ± 6.98 kg/m², respectively. Approximately two thirds (64.4%) of the sample had diabetes for >5 years. Insulin therapy users comprised 36.9% of the sample and 29.6% of patients were on ≥2 oral hypoglycemic agents (OHA). At 1 year, mean body mass index was 32.77 ± 6.09 kg/m², percent excess weight loss (%EWL) was 62.29 ± 23.60% and glycosylated hemoglobin (HbA1C) improved from 8.1% to 6.18%. Approximately 42.2% of the sample achieved T2D complete remission. Compared with those with no remission, patients with complete remission were significantly younger, had shorter duration of diabetes, were not on insulin therapy, took fewer OHA, had higher C-peptide, lower preoperative HbA1C, were less likely to have had hypertension or dyslipidemia, and more likely to have achieved higher %EWL. Seven proposed models for prediction of complete remission showed the most useful model comprised diabetes duration + pre-HbA1C + %EWL + insulin therapy + age + OHA (area under the curve = .81). Independent predictors of complete remission were preoperative HbA1C, %EWL, insulin therapy, age, and OHA (but not diabetes duration).

CONCLUSION

SG results in significant weight reduction and various extents of T2D remission. HbA1C, %EWL, insulin therapy, age, and OHA were independent predictors of complete remission. Assessing these factors before bariatric surgery is important to identify any modifiable characteristics that can be altered to increase the likelihood of remission.

New Metrics to Assess Type 2 Diabetes After Bariatric Surgery: The "Time-Within-Remission Range"

Almost one third of patients do not achieve type 2 diabetes remission after bariatric surgery or are unable to sustain this effect long term. Our objective was to delve further into the dynamic responses of diabetes after bariatric surgery and to evaluate the "time-within-remission range" as a variable of metabolic control. A descriptive cohort study was done using a computerised multicentre and multidisciplinary registry. All data were adjusted by propensity score. A total of 1186 subjects with a follow-up of 4.5 ± 2.5 years were included. Type of surgery, diabetes remission, recurrence of diabetes, "time-within-remission range" and key predictors of diabetes outcomes were assessed. All patients (70% women, 51.4 ± 9.2 years old, body mass index (BMI) 46.3 ± 6.9 kg/m2) underwent primary bariatric procedures. "Time-within-remission range" were 83.3% (33.3-91.6) after gastric bypass, 68.7% (7.1-87.5) after sleeve gastrectomy and 90% (83.3-92.8) after malabsorptive techniques (p < 0.001 for all). Duration of diabetes, baseline HbA1c and insulin treatment were significantly negatively correlated with the "time-within-remission range". The association of bariatric techniques with "time-within-remission range", using gastric bypass as a reference, were: odds ratio (OR) 3.70 (2.34-5.84), p < 0.001 for malabsorptive techniques and OR 0.55 (0.40-0.75), p < 0.001 for sleeve gastrectomy. Characteristics of type 2 diabetes powerfully influence the outcomes of bariatric surgery. The "time-within-remission range" unveils a superiority of gastric bypass compared to sleeve gastrectomy.

Validating Risk Prediction Models of Diabetes Remission After Sleeve Gastrectomy

INTRODUCTION

Many risk prediction models of diabetes remission after bariatric and metabolic surgery have been proposed. Most models have been created using Roux-en-Y gastric bypass cohorts. However, validation of these models in sleeve gastrectomy (SG) is limited. The objective of our study is to validate the performance of risk prediction models of diabetes remission in obese patients with diabetes who underwent SG.

METHOD

This retrospective cohort study included 128 patients who underwent SG with at least 1 year follow-up from Dec 2011 to Sep 2016 as the validation cohort. A literature review revealed total 11 models with 2 categories (scoring system and logistic regression), which were validated by our study dataset. Discrimination was evaluated by area under the receiver operating characteristic (AUC) while calibration by Hosmer-Lemeshow test and predicted versus observed remission ratio.

RESULTS

At 1 year after surgery, 71.9% diabetes remission (HbA1c < 6.0 off medication) and 61.4% excess weight loss were observed. Individual metabolic surgery, ABCD, DiaRem, Advanced-DiaRem, DiaBetter, Ana et al., and Dixon et al. models showed excellent discrimination power (AUC > 0.8). In calibration, all models overestimated diabetes remission from 5 to 30% but did not lose their goodness of fit.

CONCLUSION

This is the first comprehensive external validation of current risk prediction models of diabetes remission at 1 year after SG. Seven models showed excellent predicting power, and scoring models were recommended more because of their easy utility.

Endoscopic Sleeve Gastroplasty in 109 Consecutive Children and Adolescents With Obesity: Two-Year Outcomes of a New Modality

OBJECTIVES

Endoscopic sleeve gastroplasty (ESG) uses full-thickness sutures that restrict the stomach to a sleeve-like configuration. There is no published evidence on endoscopic tissue apposition techniques in pediatric patients. In this article, we report our ESG experience with the first 109 pediatric patients with obesity who underwent ESG under our care.

METHODS

ESG was offered as a day-case procedure under a standardized protocol and clinical pathway that included surgical, medical, and endoscopic modalities for the treatment of pediatric and adult obesity. ClinicalTrials.gov Identifier: NCT03778697.

RESULTS

The 109 patients in this study had a baseline body mass index and age of 33.0 ± 4.7 and 17.6 ± 2.2 (range: 10-21) years, respectively. Ninety-nine (90.8%) were females. The mean procedure time was 61 ± 19 minutes. The mean % total weight loss at 6, 12, 18, and 24 months was 14.4% ± 6.5%, 16.2% ± 8.3%, 15.4% ± 9.2%, and 13.7% ± 8.0%, respectively. Fourteen adolescents visited the ambulatory clinic for analgesia. One patient (aged 19.8 years) requested removal of endoscopic stitches due to abdominal pain, and another underwent Redo-ESG for insufficient weight loss. There were no blood transfusions, emergency admissions, mortality, or significant morbidity.

DISCUSSION

In this first study to date on ESG in pediatric patients, we observed that the procedure is safe and effective in children and adolescents with obesity. Significant weight loss occurs during the first 2 years without mortality or significant morbidity, and this weight loss seems to be maintained.

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

PURPOSE

Metabolic surgery has been performed as a treatment option for uncontrolled type 2 diabetes (T2D), and several scoring systems for predicting postoperative T2D remission have been proposed. This study was designed to assess consistency of 3 existing scoring systems in patients with T2D duration <1 year.

METHODS

This study included 186 patients with T2D enrolled in a university hospital prospective database between 2011 and 2013. Externally validated scoring systems for predicting T2D prognosis after metabolic surgery were identified and selected through systematic literature search. We assessed concordance between ABCD, DiaRem, and individualized metabolic surgery (IMS) scores in participants using kappa statistical analysis and 1-way analysis of variance.

RESULTS

Of the participants, 52 and 82 patients were expected to have favorable T2D remission after metabolic surgery with ABCD score of 10-5 and DiaRem score of 0-7, respectively, and a slight-to-fair concordance was shown between the 2 scoring systems (kappa measure, 0.07; standard error [SE], 0.05 and kappa measure, 0.25; SE, 0.19, respectively). The DiaRem score increased with T2D severity determined by IMS score (P < 0.001), while the ABCD score showed no significant association with IMS score.

CONCLUSION

ABCD and DiaRem scores showed significant discordance when applied to potential metabolic surgery candidates in whom postoperative T2D remission rate was highly expected. The IMS score showed a dose-response association with DiaRem score but had no significant association with the ABCD score.

The Effects of Bariatric Surgery on Islet Function, Insulin Secretion, and Glucose Control

Although bariatric surgery was developed primarily to treat morbid obesity, evidence from the earliest clinical observations to the most recent clinical trials consistently demonstrates that these procedures have substantial effects on glucose metabolism. A large base of research indicates that bariatric surgeries such as Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), and biliopancreatic diversion (BPD) improve diabetes in most patients, with effects frequently evident prior to substantial weight reduction. There is now unequivocal evidence from randomized controlled trials that the efficacy of surgery is superior to intensive life-style/medical management. Despite advances in the clinical understanding and application of bariatric surgery, there remains only limited knowledge of the mechanisms by which these procedures confer such large changes to metabolic physiology. The improvement of insulin sensitivity that occurs with weight loss (e.g., the result of diet, illness, physical training) also accompanies bariatric surgery. However, there is evidence to support specific effects of surgery on insulin clearance, hepatic glucose production, and islet function. Understanding the mechanisms by which surgery affects these parameters of glucose regulation has the potential to identify new targets for therapeutic discovery. Studies to distinguish among bariatric surgeries on key parameters of glucose metabolism are limited but would be of considerable value to assist clinicians in selecting specific procedures and investigators in delineating the resulting physiology. This review is based on literature related to factors governing glucose metabolism and insulin secretion after the commonly used RYGB and VSG, and the less frequently used BPD and adjustable gastric banding.

Bariatric/Metabolic Surgery in Type 1 and Type 2 Diabetes Mellitus

The prevalence of type 2 diabetes mellitus (T2DM) and obesity shows a gradual increase nowadays. Despite the introduction of multiagent treatment modalities, many patients with T2DM still do not have good results. Bariatric/metabolic surgery performed in obese patients to attain weight loss has been shown to improve T2DM. Type 1 diabetes mellitus is another type of diabetes that also shows an increase in prevalence. The aim of the present study was to evaluate the literature about the bariatric/metabolic surgical procedures performed in patients with type 1 and type 2 diabetes.